text
stringlengths 3.05k
65.3k
| source
stringlengths 36
118
| doc_id
stringlengths 32
32
| chunk_id
stringlengths 34
35
|
|---|---|---|---|
Stedi maintains this guide based on public documentation from CGS Medicare. Contact CGS Medicare for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment Advice (X221A1) X12 Release 5010 Revised November 17, 2023 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution. Delimiters Segment Element Component Repetition View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice- x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 POWERED BY Build EDI implementation guides at stedi.com 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 1 125 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0100 Transaction Set Header Max use 1 Required BPR 0200 Financial Information Max use 1 Required TRN 0400 Reassociation Trace Number Max use 1 Required CUR 0500 Foreign Currency Information Max use 1 Optional REF 0600 Receiver Identification Max use 1 Optional REF 0600 Version Identification Max use 1 Optional DTM 0700 Production Date Max use 1 Optional Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional Detail Header Number Loop LX 0030 Header Number Max use 1 Required TS3 0050 Provider Summary Information Max use 1 Optional TS2 0070 Provider Supplemental Summary Information Max use 1 Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 2 125 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Corrected Patient Insured Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Insured or Subscriber Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Statement From or To Date Max use 2 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional Summary 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 3 125 PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 4 125 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250130 1107 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 5 125 Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 6 125 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 7 125 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HP XXXXXXX XXXXXXX 20250130 1011 00 X 005010X2 21A1 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 8 125 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X221A1 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 9 125 Heading ST 0100 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 835 0001 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 10 125 BPR 0200 Heading BPR Financial Information To indicate the beginning of a Payment Order Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and or information from payer to payee to occur Usage notes Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPR I 00 C ACH CTX 01 XXXXXX DA XXX XXXXXXXXXX XX XXXXXXX 01 XXXXXX SG XXX 20250130 If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Sender DFI Identifier (BPR-07) is present, then the other is required If Account Number Qualifier (BPR-08) is present, then Sender Bank Account Number (BPR-09) is required If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-12) or Receiver or Provider Bank ID Number (BPR-13) is present, then the other is required If Account Number Qualifier (BPR-14) is present, then Receiver or Provider Account Number (BPR-15) is required Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties C Payment Accompanies Remittance Advice Use this code to instruct your third party processor to move both funds and remittance detail together through the banking system. D Make Payment Only Use this code to instruct your third party processor to move only funds through the banking system and to ignore any remittance information. H Notification Only Use this code when the actual provider payment (BPR02) is zero and the transaction is not being used for Prenotification of Future Transfers. This indicates remittance information without any associated payment. I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. P Prenotification of Future Transfers This code is used only by the payer and the banking system to initially validate account numbers before beginning an EFT relationship. Contact your VAB for additional information. U Split Payment and Remittance Use this code to instruct the third party processor to split the payment and remittance detail, and send each on a separate path. X Handling Party's Option to Split Payment and Remittance Use this code to instruct the third party processor to move the payment and remittance detail, either together or separately, based upon end point requests or capabilities. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 11 125 BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount BPR02 specifies the payment amount. Usage notes Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). BPR-03 478 Credit or Debit Flag Code Identifier (ID) Required Code indicating whether amount is a credit or debit C Credit Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment. BPR-04 591 Payment Method Code Identifier (ID) Required Code identifying the method for the movement of payment instructions ACH Automated Clearing House (ACH) Use this code to move money electronically through the ACH, or to notify the provider that an ACH transfer was requested. When this code is used, see BPR05 through BPR15 for additional requirements. CHK Check Use this code to indicate that a check has been issued for payment. NON Non-Payment Data Use this code when the Transaction Handling Code (BPR01) is H, indicating that this is information only and no dollars are to be moved. BPR-05 812 Payment Format Code Identifier (ID) Optional Code identifying the payment format to be used CCP Cash Concentration Disbursement plus Addenda (CCD ) (ACH) Use the CCD format to move money and up to 80 characters of data, enough to reassociate dollars and data when the dollars are sent through the ACH and the data is sent on a separate path. The addenda must contain a copy of the TRN segment. CTX Corporate Trade Exchange (CTX) (ACH) Use the CTX format to move dollars and data through the ACH. The CTX format can contain up to 9,999 addenda records of 80 characters each. The CTX encapsulates the complete 835 and all envelope segments. BPR-06 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 12 125 When using this transaction set to initiate a payment, all or some of BPR06 through BPR16 may be required, depending on the conventions of the specific financial channel being used. BPR06 and BPR07 relate to the originating depository financial institution (ODFI). Usage notes BPR06 through BPR09 relate to the originating financial institution and the originator's account (payer). 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. BPR-07 507 Sender DFI Identifier Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution sending the transaction into the applicable network. BPR-08 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR08 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR09. DA Demand Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order. Usage notes Use this number for the originator's account number at the financial institution. BPR-10 509 Payer Identifier Min 10 Max 10 String (AN) Optional A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. BPR10 shall be mutually established between the originating depository financial institution (ODFI) and the company originating the payment. BPR-11 510 Originating Company Supplemental Code Min 9 Max 9 String (AN) Optional A code defined between the originating company and the originating depository financial institution (ODFI) that uniquely identifies the company initiating the transfer instructions Usage notes 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 13 125 Use this code to further identify the payer by division or region. The element must be left justified and space filled to meet the minimum element size requirements. If used, this code must be identical to TRN04, excluding trailing spaces. BPR-12 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) BPR12 and BPR13 relate to the receiving depository financial institution (RDFI). Usage notes BPR12 through BPR15 relate to the receiving financial institution and the receiver's account. 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution receiving the transaction from the applicable network. BPR-14 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR14 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR15. DA Demand Deposit SG Savings BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR15 is the account number of the receiving company to be debited or credited with the payment order. Usage notes Use this number for the receiver's account number at the financial institution. BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 14 125 Usage notes Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is NON', enter the date of the 835. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 15 125 TRN 0400 Heading TRN Reassociation Trace Number To uniquely identify a transaction to an application Usage notes This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. Example TRN 1 XXXXX XXXXXXXXXX XX Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN02 provides unique identification for the transaction. Usage notes This number must be unique within the sender receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non- payment 835, this must be a unique remittance advice identification number. See 1.10.2.3, Reassociation of Dollars and Data, for additional information. TRN-03 509 Payer Identifier Min 10 Max 10 String (AN) Required A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. TRN03 identifies an organization. Usage notes This must be a 1 followed by the payer's EIN (or TIN). TRN-04 127 Originating Company Supplemental Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN04 identifies a further subdivision within the organization. Usage notes 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 16 125 If both TRN04 and BPR11 are used, they must be identical, excluding trailing spaces. Since BPR11 has a min max value of 9 9, whenever both are used, this element is restricted to a maximum size of 9. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 17 125 CUR 0500 Heading CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes When the CUR segment is not present, the currency of payment is defined as US dollars. Required when the payment is not being made in US dollars. If not required by this implementation guide, do not send. Example CUR PR XXX Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 18 125 REF 0600 Heading REF Receiver Identification To specify identifying information Usage notes This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee. Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example REF EV XX Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 19 125 REF 0600 Heading REF Version Identification To specify identifying information Usage notes Update this reference number whenever a change in the version or release number affects the 835. (This is not the ANSI ASCX12 version number as reported in the GS segment.) Required when necessary to report the version number of the adjudication system that generated the claim payments in order for the payer to resolve customer service questions from the payee. If not required by this implementation guide, do not send. Example REF F2 XX Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 20 125 DTM 0700 Heading DTM Production Date To specify pertinent dates and times Usage notes If your adjudication cycle completed on Thursday and your 835 is produced on Saturday, you are required to populate this segment with Thursday's date. Required when the cut off date of the adjudication system remittance run is different from the date of the 835 as identified in the related GS04 element. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example DTM 405 20250130 Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes Report the end date for the adjudication production cycle for claims included in this 835. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 21 125 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading Payer Identification Loop N1 Payer Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information for the payer. The payer's secondary identifying reference number is provided in N104, if necessary. Example N1 PR XXXX XV XXXXX If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). N1-04 67 Payer Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 22 125 N3 1000 Heading Payer Identification Loop N3 Payer Address To specify the location of the named party Example N3 XXXX XXX Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 23 125 N4 1100 Heading Payer Identification Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXXXXXX XX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 24 125 REF 1200 Heading Payer Identification Loop REF Additional Payer Identification To specify identifying information Usage notes The ID available in the TRN and N1 segments must be used before using the REF segment. Required when additional payer identification numbers beyond those in the TRN and Payer N1 segments are needed. If not required by this implementation guide, may be sent at sender's discretion, but cannot be required by the receiver. Example REF 2U XXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number For Medicare carriers or intermediaries, use this qualifier for the Medicare carrier or intermediary ID number. For Blue Cross and Blue Shield Plans, use this qualifier for the Blue Cross Blue Shield association plan code. REF-02 127 Additional Payer Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes CGS reference ID 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 25 125 PER 1300 Heading Payer Identification Loop PER Payer Business Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send. Example PER CX XX FX XXXXX FX XXXX EX XXXXX Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 26 125 PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 27 125 PER 1300 Heading Payer Identification Loop PER Payer Technical Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required to report technical contact information for this remittance advice. Example PER BL XX UR XXXX FX XXXXXX EM XX Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail TE Telephone Recommended UR Uniform Resource Locator (URL) Use only when there is no central telephone number for the payer entity. PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 28 125 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile TE Telephone UR Uniform Resource Locator (URL) PER-06 364 Payer Technical Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile UR Uniform Resource Locator (URL) PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 29 125 1000A Payer Identification Loop end PER 1300 Heading Payer Identification Loop PER Payer WEB Site To identify a person or office to whom administrative communications should be directed Usage notes Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PER IC UR XXXXX Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 30 125 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading Payee Identification Loop N1 Payee Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information of the payee. The identifying reference number is provided in N104. Example N1 PE XXX XX XX Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number. XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). This only applies in cases of post payment recovery. See section 1.10.2.16 (Post Payment Recovery) for further information. XX Centers for Medicare and Medicaid Services National Provider Identifier This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate. N1-04 67 Payee Identification Code Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 31 125 This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 32 125 N3 1000 Heading Payee Identification Loop N3 Payee Address To specify the location of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N3 XXXX XXXXX Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 33 125 N4 1100 Heading Payee Identification Loop N4 Payee City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N4 XXXXX XX XXX XXX Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 34 125 REF 1200 Heading Payee Identification Loop REF Payee Additional Identification To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example REF D3 XXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number D3 National Council for Prescription Drug Programs Pharmacy Number PQ Payee Identification TJ Federal Taxpayer's Identification Number This information must be in the N1 segment unless the National Provider ID or the Health Plan Identifier (HPID) or Other Entity Identifier (OEID) was used in N104. For individual providers as payees, use this number to represent the Social Security Number. TJ also represents the Employer Identification Number (EIN). According to the IRS, TIN and EIN can be used interchangeably. REF-02 127 Additional Payee Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 35 125 RDM 1400 Heading Payee Identification Loop RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes Required when BPR01 U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM BM X XX Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 36 125 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 37 125 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 0 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set Usage notes Medicare will send 1 for Assigned or 0 for NonAssigned. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 38 125 TS3 0050 Detail Header Number Loop TS3 Provider Summary Information To supply provider-level control information Usage notes TS301 identifies the subsidiary provider. The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part | /kaggle/input/edi-db-835-837/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_0 |
the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM BM X XX Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 36 125 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 37 125 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 0 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set Usage notes Medicare will send 1 for Assigned or 0 for NonAssigned. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 38 125 TS3 0050 Detail Header Number Loop TS3 Provider Summary Information To supply provider-level control information Usage notes TS301 identifies the subsidiary provider. The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000. Required for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity i.e., the corporate office of a hospital chain. If not required by this implementation guide, do not send. Example TS3 X X 20250130 0000000000 000 0000000000 000 00000000000 000000000 0000000 0 0000000000 00 00000000000000 0000000 00 Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes When reporting a TS3 segment for professional claims and the claims are not all for the same place of service, report a place of service of 11 (Office) as the default value. When reporting a TS3 segment for pharmaceutical claims and the claims are not all for the same place of service, report a place of service of 99 (Other unlisted facility) as the default value. TS3-03 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year TS303 is the last day of the provider's fiscal year. Usage notes 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 39 125 Use this date for the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known, use December 31st of the current year. TS3-04 380 Total Claim Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity TS304 is the total number of claims. Usage notes This is the total number of claims. TS3-05 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount TS305 is the total of reported charges. Usage notes This is the total reported charges for all claims. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all 782 elements. TS3-13 782 Total MSP Payer Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS313 is the total Medicare Secondary Payer (MSP) primary payer amount. Usage notes See TR3 note 3. TS3-15 782 Total Non-Lab Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS317 is the Health Care Financing Administration Common Procedural Coding System (HCPCS) reported charges. Usage notes See TR3 note 3. TS3-18 782 Total HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 40 125 Monetary amount TS318 is the total Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes See TR3 note 3. TS3-20 782 Total Professional Component Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS320 is the total professional component amount. Usage notes The professional component amount must also be reported in the CAS segment with a Claim Adjustment Reason Code value of 89. See TR3 note 3. TS3-21 782 Total MSP Patient Liability Met Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS321 is the total Medicare Secondary Payer (MSP) patient liability met. Usage notes See TR3 note 3. TS3-22 782 Total Patient Reimbursement Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS322 is the total patient reimbursement. Usage notes See TR3 note 3. TS3-23 380 Total PIP Claim Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS323 is the total periodic interim payment (PIP) number of claims. Usage notes See TR3 note 3. TS3-24 782 Total PIP Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 41 125 See TR3 note 3. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 42 125 TS2 0070 Detail Header Number Loop TS2 Provider Supplemental Summary Information To provide supplemental summary control information by provider fiscal year and bill type Usage notes This segment provides summary information specific to an iteration of the LX loop (Table 2). Each element represents the total value for the provider bill type combination in this loop 2000 iteration. Required for Medicare Part A. If not required by this implementation guide, do not send. Example TS2 0000000000000 000000 000 0000000000000 0000 0 00000000000000 0000000 000 0000 0000 000000000000 000 0000000000 00 0000000000 0 00000000 000000000 00000 0 000000000 Max use 1 Optional TS2-01 782 Total DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS201 is the total diagnosis related group (DRG) amount. Usage notes This includes: operating federal-specific amount, operating hospital-specific amount, operating Indirect Medical Education amount, and operating Disproportionate Share Hospital amount. It does not include any operating outlier amount. See TR3 note 2. TS2-02 782 Total Federal Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS202 is the total federal specific amount. Usage notes See TR3 note 2. TS2-03 782 Total Hospital Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS203 is the total hospital specific amount. Usage notes See TR3 note 2. TS2-04 782 Total Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS204 is the total disproportionate share amount. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 43 125 Usage notes See TR3 note 2. TS2-05 782 Total Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS205 is the total capital amount. Usage notes This includes: capital federal-specfic amount, hospital federal-specfic amount, hold harmless amount, Indirect Medical Education amount, Disproportionate Share Hospital amount, and the exception amount. It does not include any capital outlier amount. See TR3 note 2. TS2-06 782 Total Indirect Medical Education Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS206 is the total indirect medical education amount. Usage notes See TR3 note 2. TS2-07 380 Total Outlier Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS207 is the total number of outlier days. Usage notes See TR3 note 2. TS2-08 782 Total Day Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS208 is the total day outlier amount. Usage notes See TR3 note 2. TS2-09 782 Total Cost Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS209 is the total cost outlier amount. Usage notes See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 44 125 TS210 is the diagnosis related group (DRG) average length of stay. Usage notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS211 is the total number of discharges. Usage notes This is the discharge count produced by PPS PRICER SOFTWARE. See TR3 note 2. TS2-12 380 Total Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS212 is the total number of cost report days. Usage notes See TR3 note 2. TS2-13 380 Total Covered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS213 is the total number of covered days. Usage notes See TR3 note 2. TS2-14 380 Total Noncovered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS214 is total number of non-covered days. Usage notes See TR3 note 2. TS2-15 782 Total MSP Pass-Through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer. Usage notes See TR3 note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 45 125 Numeric value of quantity TS216 is the average diagnosis-related group (DRG) weight. Usage notes See TR3 note 2. TS2-17 782 Total PPS Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS217 is the total prospective payment system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-18 782 Total PPS Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-19 782 Total PPS DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 46 125 2100 Claim Payment Information Loop Max 1 Required CLP 0100 Detail Header Number Loop Claim Payment Information Loop CLP Claim Payment Information To supply information common to all services of a claim Usage notes For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations. Example CLP XXX 20 00 0000000 000000000000000 12 XXXX X X X XX 0 0 Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format). CLP-02 1029 Claim Status Code Identifier (ID) Required Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization Usage notes To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code. 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied Usage of this code would apply if the Patient Subscriber is not recognized, and the claim was not forwarded to another payer. 19 Processed as Primary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 20 Processed as Secondary, Forwarded to Additional Payer(s) 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 47 125 When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 22 Reversal of Previous Payment See section 1.10.2.8 for usage information. 23 Not Our Claim, Forwarded to Additional Payer(s) Usage of this code would apply if the patient subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required. CLP-03 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CLP-04 782 Claim Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 48 125 Code identifying type of claim Usage notes For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2- 005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835. The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer. Medicare will send MB for Part B and DME. Medicare will send MA for Part A. 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) MA Medicare Part A MB Medicare Part B MC Medicaid CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 49 125 Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 50 125 CAS 0200 Detail Header Number Loop Claim Payment Information Loop CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note 1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CAS OA XX 0000000000 0 X 000000 000000000 XXXX 00 00 00000000000 XXXXX 000 00000000000 XXXX 0000000 00000 000000 XX 0000 000000000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 51 125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. A positive value decreases the covered days, and a negative number increases the covered days. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 52 125 CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 53 125 Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 54 125 CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 55 125 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Patient Insured Name To supply the full name of an individual or organizational entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send. Example NM1 74 1 XXX XXXXX XXXXX XXX C XX Variants (all may be used) NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 74 Corrected Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 56 125 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 57 125 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1 PR 2 XX XV XXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 58 125 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 59 125 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1 TT 2 X PI XXXXXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 60 125 PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Crossover Carrier Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 61 125 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Insured or Subscriber To supply the full name of an individual or organizational entity Example NM1 IL X XXX XXXXX XX XXXXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Corrected Priority Payer Identification Number (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Min 1 Max 1 Identifier (ID) Optional Code qualifying the type of entity NM102 qualifies NM103. NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Name First Min 1 Max 35 String (AN) Optional Individual first name NM1-08 66 Identification Code Qualifier Min 1 Max 2 Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 62 125 Code identifying a party or other code 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 63 125 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1 GB 2 XXX X XXXXX XXXX MI XX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 64 125 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 65 125 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1 QC 1 XXXXX XXXXX XXXX XX MI XXXXXXX XX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 66 125 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) MI Member Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 67 125 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1 82 2 XXXXXX XXXXX XXXXXX X XX XXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 68 125 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number FI Federal Taxpayer's Identification Number This is the preferred ID until the National Provider ID is mandated and applicable. For individual providers as payees, use this qualifier to represent the Social Security Number. MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 69 125 MIA 0330 Detail Header Number Loop Claim Payment Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA 0 000000000000 0000000000000 00 XXXXXX 0000 0 0 00 0 0000 00000000000 00000 000000 000 000000 0 0000000000000 00000000000 0000 00000000000000 0 XX XX XXX XXXX 0000000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 70 125 Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max | /kaggle/input/edi-db-835-837/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_1 |
provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 69 125 MIA 0330 Detail Header Number Loop Claim Payment Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA 0 000000000000 0000000000000 00 XXXXXX 0000 0 0 00 0 0000 00000000000 00000 000000 000 000000 0 0000000000000 00000000000 0000 00000000000000 0 XX XX XXX XXXX 0000000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 70 125 Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 71 125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 72 125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 73 125 MOA 0350 Detail Header Number Loop Claim Payment Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA 000 00000000000 XXXXX XXXXXX XXX XX XXXXX 000 0000000 00000000000000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 74 125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 75 125 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REF CE XXX Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known. 28 Employee Identification Number CE Class of Contract Code EA Medical Record Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. TJ Federal Taxpayer's Identification Number REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 76 125 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM 050 20250130 Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 77 125 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM 036 20250130 Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 78 125 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 232 20250130 Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 79 125 PER 0600 Detail Header Number Loop Claim Payment Information Loop PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PER CX XXX EM XXXXXX EX XXXXX EX XXX If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 80 125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 81 125 AMT 0620 Detail Header Number Loop Claim Payment Information Loop AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT ZL 00000 Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 82 125 QTY 0640 Detail Header Number Loop Claim Payment Information Loop QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTY LA 0000 Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual OU Outlier Days ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 83 125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78 25 ). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVC HP XX XX XX XX XX 0000 000000000000 XXXXX 000 000000000000 HC XXXXXX XX XX XX XX X 0000000000 Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 84 125 AD American Dental Association Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 85 125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 86 125 HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 87 125 Numeric value of quantity SVC07 is the original submitted units of service. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 88 125 DTM 0800 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 151 20250130 Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 89 125 CAS 0900 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS OA XXXXX 0000000000 000 XX 000000 00000000000 00 XXX 0000000000000 000000000000 X 000000000000 0 000000000000000 XX 0000000000 00000000000000 XX XX 0 00000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 90 125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 91 125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 92 125 See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 93 125 CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 94 125 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF 0K XX Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 95 125 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF 6R XXXX Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 96 125 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REF HPI XXXXXX Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1C Medicare Provider Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 97 125 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REF RB X Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 98 125 AMT 1100 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT ZM 00000000 Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 99 125 QTY 1200 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTY ZO 00000000000 Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 100 125 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required | /kaggle/input/edi-db-835-837/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_2 |
Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT ZM 00000000 Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 99 125 QTY 1200 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTY ZO 00000000000 Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 100 125 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQ HE XXX Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 101 125 Summary PLB 0100 Summary PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLB XXXX 20250130 IS XXXX 0000000000 XX XXX 00000 0000 XX X 0000000 XX XXXX 000000000000000 XX XXXX X 0000 XX XXXXXX 000000000000000 If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use 1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 102 125 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 103 125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 104 125 TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source). C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Use when necessary to assist the receiver in identifying, tracking or reconcilling the adjustment. See sections 1.10.2.10 (Capitation and Related Payments), 1.10.2.5 (Advanced Payments and Reconciliation) and 1.10.2.12 (Balance Forward Processing) for further information. PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PLB04 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. PLB-05 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB05 is the adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 105 125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB06 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-07 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB07 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-08 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB08 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-09 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 106 125 Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-10 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB10 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-11 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB11 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-12 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB12 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-13 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB13 is adjustment information as defined by the payer. Usage notes Max use 1 Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 107 125 Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 108 125 Summary end SE 0200 Summary SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 000000 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 109 125 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 0000 00000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 110 125 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 0000 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 111 125 EDI Samples Example 1: Dollars and Data Sent Separately ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 112233 BPR I 1100 C ACH CCP 01 888999777 DA 24681012 1935665544 01 111333555 DA 144444 20190316 TRN 1 71700666555 1935665544 DTM 405 20190314 N1 PR RUSHMORE LIFE N3 10 SOUTH AVENUET N4 RAPID CITY SD 55111 PER BL JOHN WAYNE TE 8005551212 EX 123 N1 PE ACME MEDICAL CENTER XX 5544667733 REF TJ 777667755 LX 1 CLP 5554555444 1 800 500 300 12 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT AU 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 12 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT AU 1200 SVC HC 93555 1200 600 DTM 472 20190310 CAS PR 1 600 AMT B6 1200 SE 26 112233 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 112 125 Example 2: Multiple Claims Single Check ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1512345678 REF EV XYZ CLEARINGHOUSE N1 PR DENTAL OF ABC N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC XX 9999947036 REF TJ 212121212 LX 1 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 DOE SANDY MI SJD11112 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 119 74 12 119932404007801 11 1 NM1 QC 1 DOE SALLY MI SJD11111 NM1 IL 1 DOE JOHN MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 74 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 12 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 113 125 AMT B6 25 SVC AD D0220 25 0 DTM 472 20190324 CAS PR 3 14 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 0 DTM 472 20190324 CAS PR 3 10 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 1145 14 902 12 119932404007801 11 1 NM1 QC 1 SMITH SAM MI SJD11116 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 14 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D2790 940 0 DTM 472 20190324 CAS PR 3 756 CAS CO 45 184 SVC AD D2950 180 0 DTM 472 20190324 CAS PR 3 146 CAS CO 45 34 CLP 7722337 1 348 16.8 44.2 12 119932404007801 11 1 NM1 QC 1 JONES SAM MI SJD11122 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 28 SVC AD D4342 125 0 DTM 472 20190313 CAS CO 45 125 SVC AD D4381 43 0 DTM 472 20190313 CAS PR 3 33 CAS CO 45 10 SVC AD D2950 180 16.8 DTM 472 20190313 CAS PR 3 11.2 CAS CO 45 152 AMT B6 28 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 JONES SALLY MI SJD11133 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190321 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 114 125 DTM 472 20190321 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190321 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190321 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190321 CAS CO 45 24 AMT B6 49 CLP 7722337 1 179 108 12 119932404007801 11 1 NM1 QC 1 DOE SAM MI SJD99999 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 108 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 129 82 12 119932404007801 11 1 NM1 QC 1 DOE SUE MI SJD88888 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 CLP 7722337 1 221 144 12 119932404007801 11 1 NM1 QC 1 DOE DONNA MI SJD77777 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 144 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0330 92 62 DTM 472 20190324 CAS CO 45 30 AMT B6 62 SVC AD D1120 54 37 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 115 125 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 SE 183 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 116 125 Example 3: Claim Specific Negotiated Discount ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 132 C CHK 20190331 TRN 1 12345 1512345678 REF EV CLEARINGHOUSE N1 PR DELTA DENTAL OF ABC N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC FI 999994703 LX 1 CLP 7722337 1 226 132 12 119932404007801 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 131 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 131 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 131 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 131 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 131 24 AMT B6 49 SE 35 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 117 125 Example 4: Claim Adjustment Reason Code 45 ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 80.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 400 80 MC CLAIMNUMBER 11 1 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004074627 AMT AU 150 SVC HC 99213 150 80 1 DTM 472 20190101 CAS CO 45 70 AMT B6 80 SVC HC 85003 100 0 1 DTM 472 20190101 CAS CO 204 100 SVC HC 36415 150 0 1 DTM 472 20190101 CAS CO 97 150 SE 33 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 118 125 Example 5a: Line Service Tax impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 11.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 36.20 11.06 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 36.20 SVC HC 99214 26.2 3.06 DTM 472 20170109 CAS CO 45 23.2 137 -.06 REF 6R B1 AMT B6 3 SVC HC 36415 10 8 DTM 472 20170109 CAS CO 45 2 REF 6R B2 AMT B6 8 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 119 125 Example 5b: Line Service Bonuses impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 12.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 12 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 12 DTM 472 20170109 CAS CO 45 5 161 -2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 120 125 Example 5c: Line Service Penalty impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 8 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 8 DTM 472 20170109 CAS CO 45 5 B4 2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 121 125 Example 6: Not Covered Not Authorized Inpatient Facility claim days ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8000.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 40000 8000 MC CLAIMNUMBER 11 1 CAS CO 197 2000 1 45 30000 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 232 20190101 DTM 233 20190105 DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004001212 AMT AU 38000 QTY CA 4 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 122 125 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 120.03 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 04777796TLC777122 1 155 120.03 13 8838888212 11 1 NM1 QC 1 MASTERS MARVIN L MI 80444444403 NM1 IL 1 CABLE MABEL MI 80444444403 NM1 74 1 MASTERS MARVIN C 80444444401 NM1 82 1 SHELTON MD BLAKE XX 1666666666 REF 1L 28 REF CE HSOAP-LAOA REF TJ 555555555 DTM 232 20191114 DTM 233 20181114 DTM 050 20181119 AMT AU 155 SVC HC 99393 155 120.03 1 DTM 472 20181114 CAS CO 45 34.97 REF LU 11 REF 6R 22261822 AMT B6 120.03 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 123 125 Example 8b: Claim submitted with incorrect subscriber name and ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 35.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 02333TLC222222 1 115 35.06 35 13 8333333214 11 1 NM1 QC 1 KEATON ALEX P MI 80000006006 NM1 IL 1 THOMAS JASON MI 80000006006 NM1 74 1 JEROME C 80000006001 NM1 82 1 BLOOD MD RED N XX 1888888886 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191113 DTM 233 20191113 DTM 050 20191119 AMT AU 115 SVC HC 99213 115 35.06 1 DTM 472 20191113 CAS CO 45 44.94 CAS PR 3 35 REF LU 11 REF 6R 22261389 AMT B6 70.06 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 124 125 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 2415.25 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 05444444TLC999999 1 3903 2415.25 13 8777777782 21 1 NM1 QC 1 GONZALES SAMMY MI 80455555502 NM1 IL 1 LAPLANTE FERN MI 80455555502 NM1 74 1 R NM1 82 1 GOOD MD ROBERT B XX 19999999987 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191101 DTM 233 20191101 DTM 050 20191114 AMT AU 3903 AMT F5 150 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF LU 21 REF 6R 22215592 AMT B6 2415.25 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 125 125 | /kaggle/input/edi-db-835-837/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_3 |
GAINWELL TECHNOLOGIES Louisiana Medicaid 837 Health Care Claim-Institutional Companion Guide Based on ASC X12N Version 005010X223A2 CORE v5010 Master Companion Guide Template Issued January 2018 Version 1.6 Revised 1 14 2025 837 Institutional Companion Guide i Revision History See Appendix C. Usage Information Documents published herein are furnished As Is. There are no expressed or implied warranties. The content of this document herein is subject to change without notice. 837 Institutional Companion Guide ii Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Gainwell Medicaid Solutions. Transmissions based on this Companion Guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The purpose of this guide is to clarify Louisiana Medicaid specific requirements and information needed for inclusion in the electronic 005010X223A2.claim transaction. The Companion Guide does not replace the published HIPAA Implementation TR3 Guide nor is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. All Data must be formatted in upper case. This Guide is applicable to the following Louisiana Medicaid Claim types or File extensions. UB9 Inpatient and outpatient claims HOM Home Health claims XXA Medicare Advantage claims Providers Submitters must be enrolled and registered in Louisiana Medicaid to submit electronic claims. Please review the 5010 EDI General Companion Guide: (https: www.lamedicaid.com Provweb1 HIPAABilling 5010_EDI_General_Companion.pdf). Refer to Sections 2, 3 and 4 of this 837I guide for more detailed information. 837 Institutional Companion Guide iii TABLE OF CONTENTS PREFACE...................................................................................................................................................... II 1. INTRODUCTION............................................................................................................................ 4 1.1 Scope.......................................................................................................................................... 4 1.2 Overview.................................................................................................................................... 5 1.3 References.................................................................................................................................. 5 1.4 Additional Information............................................................................................................ 6 2. GETTING STARTED............................................................................................................................. 6 2.1 Working with Louisiana Medicaid.......................................................................................... 6 2.2 Trading Partner Registration.................................................................................................. 6 2.3 Certification and Testing Overview........................................................................................ 7 3. TESTING WITH THE PAYER.............................................................................................................. 7 4. CONNECTIVITY WITH THE PAYER COMMUNICATIONS....................................................... 7 4.1 Process Flows............................................................................................................................. 7 4.2 Transmission Administrative Procedures.............................................................................. 8 4.3 Re-Transmission Procedure..................................................................................................... 8 4.4 Communication Protocol Specifications................................................................................. 8 4.4.1 EDI Gateway sFTP Process.................................................................................................. 8 4.4.2 File Naming Conventions Production and Test File Names............................................... 9 4.5 Passwords.................................................................................................................................. 9 5. CONTACT INFORMATION................................................................................................................. 9 5.1 EDI Customer Service.............................................................................................................. 9 5.2 EDI Technical Assistance......................................................................................................... 9 5.3 Provider Service Provider Enrollment............................................................................... 9 5.4 Applicable Websites Email...................................................................................................... 10 6. CONTROL SEGMENTS ENVELOPES............................................................................................... 10 6.1 ISA-IEA...................................................................................................................................... 10 6.2 GS-GE........................................................................................................................................ 11 6.3 ST-SE......................................................................................................................................... 11 7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS......................................................... 11 8. ACKNOWLEDGEMENTS AND OR REPORTS................................................................................ 13 8.1 Report Inventory....................................................................................................................... 13 9. TRADING PARTNER AGREEMENTS............................................................................................... 13 9.1 Trading Partners....................................................................................................................... 14 10. TRANSACTION SPECIFIC INFORMATION.................................................................................. 14 APPENDICES............................................................................................................................................... 40 Appendix A Implementation Checklist....................................................................................... 40 Appendix B Business Scenarios and Claim Encounter Example............................................. 40 a. Scenario 1 - CLAIMs FOR DUAL MEDICAID MEDICARE ELIGIBLE WHEN DENIED BY MEDICARE................................................................................................................................. 42 b. Scenario 2 - CLAIMS FOR RECIPIENTS WITH MEDICARE ADVANTAGE COVERAGE 44 c. Scenario 3 ENCOUNTERS FOR SUBROGATION................................................................. 48 Appendix C - Change Summary..................................................................................................... 49 Appendix D - Trading Partner Agreements (TPA)...................................................................... 50 837 Institutional Companion Guide 4 1. Introduction This section describes how Louisiana Medicaid specific Health Care Claim (837I) transaction set information will be detailed with the use of a table. The tables contain a row for each segment that Louisiana Medicaid has something additional, over and above, the information in the Technical Report Type 3 (TR3). That information can: Limit the repeat of loops, or segments. Limit the length of a simple data element. Specify a sub-set of the Implementation Guides internal code listings. Clarify the use of loops, segments, composite and simple data elements. Any other information tied directly to a loop, segment, composite or simple data element pertinent to trading electronically with Louisiana Medicaid. In addition to the row for a specific segment, one or more additional rows are used to describe Louisiana Medicaid s usage for composite and simple data elements and for any other information. Table 1: 837I Transaction Set Descriptions specifies the columns and suggested use of the rows for the detailed description of the transaction set Companion Guides. Table 1: 837I Transaction Set Descriptions Page Loop ID Reference Name Codes Length Notes Comments 2010B A NM1 Subscriber Name This type of row always exists to indicate that a new segment has begun. It is always shaded and notes or comments about the segment itself go in this cell. 2010B A NM109 Identification Code 2 80 This type of row exists to limit the length of the specified data element. 2430 SVD01 Identification Code Third Party Carrier Code Enter the Louisiana Medicaid issued Third Party Carrier Code. 1.1 Scope The purpose of the Louisiana Medicaid 837I Health Care Claim Companion Guide is to provide Trading Partners with a guide to the Louisiana Medicaid specific requirements for the 837 Institutional claim transactions. This Companion Guide document should be used in conjunction with the Technical Report Type 3 (TR3) and the national standard code sets referenced in that Guide. 837 Institutional Companion Guide 5 The 837I claims transaction is used for submittal of the following Louisiana Medicaid claim types, each with a unique file extension as part of the naming convention for the submitted file: UB9 Inpatient and Outpatient claims. HOM Home Health claims. Additional information about naming convention and file extensions can be found in the HIPAA 5010A EDI General Companion Guide (https: www.lamedicaid.com Provweb1 HIPAABilling 5010_EDI_General_Companion.pdf). 1.2 Overview This companion guide is to assist trading partners test and set up electronic claim transactions to meet Louisiana Medicaid processing standards. It documents and clarifies which data elements and segments must be used and when specific code sets or codes are to be used with Louisiana Medicaid billings. The information in this guide must be used in conjunction with the TR3 Implementation Guide instructions. This section describes how the table, for the Louisiana Medicaid specific 837I transaction, is organized by columns and their descriptions. Section 10, Table 2 837I Health Care Claim, should be used as a reference for 837I transactions submitted to Louisiana Medicaid. Table 2 contains the specific data values and descriptions used in processing the transaction. Refer to Section 10, Transaction Set Information, for more details. Column Descriptions: Page Number Corresponding page number in TR3 Implementation Guide Loop ID TR3 Implementation Guide Loop Reference TR3 Implementation Guide Segment Name TR3 Implementation Guide segment element name Codes - Data values to be sent for Louisiana Medicaid transactions. Information contained within is the description or format of the data that should be entered in the field. Length A single number denotes fixed length. Two numbers separated by a slash denotes min max length. Notes Comments Additional information specific to Louisiana Medicaid transactions. 1.3 References This section describes the additional reference material Trading Partners must use for the specific transaction specifications for the 837I Health Care Claim. Refer to the following HIPAA version 5010A2 Technical Report Type 3 for additional information not supplied in this document, such as transaction usage, examples, code lists, definitions, and edits. 837 Health Claim-Institutional 005010X223A2 Copies of the ANSI X12 Technical Report Type 3s are available for purchase from the Washington Publishing Company at the following URL: http: www.wpc-edi.com. 837 Institutional Companion Guide 6 All required information for populating the X12 EDI transactions can be found by referencing this Louisiana Medicaid 837I Companion Guide and the HIPAA Technical Report Type 3s. 1.4 Additional Information Refer to the 5010A1 Technical Report Type 3 for information not supplied in this document, such as code sources, definitions, and edits. Louisiana Medicaid policies and requirements are documented in the claim type specific provider billing manuals and training packets and provider notices found on www.lamedicaid.com. 2. Getting Started This section describes how to interact with Louisiana Medicaid regarding 837I transactions. 2.1 Working with Louisiana Medicaid The EDI Help Desk is available to assist providers with their electronic transactions from, Monday through Friday, during the hours of 8:00 am 5:00 pm Central, by calling 225-216-6303 or via email at HipaaEDI gainwelltechnologies.com. Louisiana Medicaid s MMIS system supports the following categories of Trading Partner: Provider Billing Agency Clearinghouse Health Plan NOTE: Providers must be enrolled and approved before registering as a Trading Partner. Billing Agencies Clearinghouse must be associated with an approved Billing Provider in order to register as a Trading Partner. 2.2 Trading Partner Registration To obtain a Submitter ID visit the website: lamedicaid.com and follow the steps provided in the link titled Provider Enrollment. Providers may have up to three billing agencies clearinghouse submit claims on their behalf but can select only one submitter to receive the 835 transaction. This selection is made when completing the ERA enrollment forms. All claims processed for a provider in a check write cycle will be included in the 835, regardless of method of submission (i.e. hardcopy or electronic). 837 Institutional Companion Guide 7 2.3 Certification and Testing Overview All Trading Partners are required to submit test EDI transactions before being authorized to submit production EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of any X12 file, indicates if a file is test or production. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims, but not certified to submit 837I institutional claim files 3. Testing with the Payer Trading Partners will submit two test files of a particular transaction type, with no set minimum of transactions within each file, and have no failures or rejections to become certified for production. Users will be notified (E-mail) of the Trading Partner Status when testing for a particular transaction has been completed. To test an EDI transaction type, follow the steps outlined in Section 3 in the HIPAA 5010A EDI General Companion Guide (https: www.lamedicaid.com Provweb1 HIPAABilling 5010_EDI_General_Companion.pdf). This guide provides additional information such as specific steps to follow for submitting test files, the test result reports and how to read them, file rejection reasons, etc. 4. Connectivity with the Payer Communications This section contains information relating to the exchange methods with Louisiana Medicaid for submittal of the 837I transaction. 4.1 Process Flows Submitters will use the Louisiana Medicaid EDI Gateway to submit and retrieve files electronically. Each submitter receives a mailbox where their files are stored and maintained. This mailbox is accessed to send files via the To_Molina folder and retrieve files via the From_Molina folder. 837I files are sent to the submitter s To_Molina folder and associated processing reports must be retrieved from the From_Molina folder location. Louisiana Medicaid has established the following for the EDI Gateway: Internet sFTP Connection Services: Secure File Transfer Protocol to provide an end-to-end secure tunnel with Public Private Key pair data encryption. Only Trading Partners who are approved to utilize this type of connection service may do so to submit 837I claim transactions to their secure FTP location. During the testing process with EDI Department, submitters will finalize the communication methodology to be used for file submissions and file retrievals. 837 Institutional Companion Guide 8 4.2 Transmission Administrative Procedures The TA1 and 999 transaction reports are posted to sFTP indicating whether a file has passed editing and been accepted for processing. These reports can be obtained from sFTP in the From_Molina folder for those submitters approved for that option. The deadline for claim file submission is noon on Monday through Thursday for processing in the weekend adjudication cycle. Claim files received Friday thru Sunday will be entered into the processing Daily cycle on Mondays. The Louisiana Medicaid calendar year check write schedule is posted to www.lamedicaid.com. Any variances in the check write schedule will be posted in provider notice section of www.lamedicaid.com. 4.3 Re-Transmission Procedure Providers submitters should contact the Gainwell EDI Department via email at HipaaEDI Gainwelltechnologies.com if an 837I claim file is processed late or missing. If a file is rejected, the errors must be corrected and then the file can be resubmitted but MUST have a different ISA number. An ISA number can never be reused. 4.4 Communication Protocol Specifications This section describes Louisiana Medicaid s communication protocol. The information exchanged between devices, through a network or other media, is governed by rules and conventions that can be set out in a technical specification called communication protocol standards. The nature of the communication, the actual data exchanged and any state-dependent behaviors, is defined by its specification. 4.4.1 EDI Gateway sFTP Process Louisiana Medicaid offers a secure FTP system that has been developed to allow for more reliable and expedited electronic file exchanges for trading partners. The site is located at ftp.lamedicaid.com. To facilitate increased security requirements, all files sent to and received from the Gainwell sFTP site must be encrypted using Public Private key pair encryption technology. Gainwell assumes any trading partner requesting access to the system will be familiar with how this technology is used. Gnu Privacy Guard, a free open source client, is available at http: www.gnupg.org. Symantec s PGP client is another client although it is not free. 837 Institutional Companion Guide 9 4.4.2 File Naming Conventions Production and Test File Names All electronic files sent to Gainwell must have file names in accordance with the structure below. Replace the sample submitter number of 4599999 with your assigned Louisiana Medicaid submitter number. The correct file extension is crucial to having your claims edited for the correct claim type. Transaction Claim Type Name File Extension Sample file name 837I 01,03 Institutional.UB9 H4599999.UB9 837I 06 Home Health.HOM H4599999.HOM 837I 14 Medicare Advantage.XXA H4599999.XXA 4.5 Passwords Trading Partners will be assigned a username and password during the Trading Partner Account registration process. Information for setting up the username and password is provided in Section 4.2 of the HIPAA 5010A EDI General Companion Guide located at lamedicaid.com under the HIPAA Information link. 5. Contact Information This section contains the contact information, including email addresses, for EDI Customer Service and Technical Assistance, Provider Services, and Provider Enrollment. All times are Central Time Zone. 5.1 EDI Customer Service The EDI Help Desk is available to assist providers with their electronic transactions from Monday through Friday, during the hours of 8:00 am 5:00 pm, by calling 1-225-216-6303. Or via email at HIPAAEdi Gainwelltechnologies.com 5.2 EDI Technical Assistance The EDI Help Desk is available to assist providers with their electronic transactions from Monday through Friday, during the hours of 8:00 am 5:00 pm, by calling 1-225-216-6303. 5.3 Provider Service Provider Enrollment The Provider Services Call Center is available to assist providers concerning the payment of claims from Monday through Friday, during the hours of 8:00 am 5:00 pm, by calling 1-225-924-5040 or 1-800- 473-2783. The Provider Enrollment Department is available to assist provider with enrollment, changes to submitters, etc., Monday through Friday, during the hours of 8:00 am 5:00 pm by calling 1-225-216- 6370. 837 Institutional Companion Guide 10 5.4 Applicable Websites Email For questions related to electronic Data interchange and EDI issues, the EDI Department can be contacted at: HipaaEDI Gainwelltechnologies.com. 6. Control Segments Envelopes This section describes Louisiana Medicaid s use of the interchange, functional group control segments and the transaction set control numbers. 6.1 ISA-IEA This section describes Louisiana Medicaid s use of the interchange control segments. Interchange Control Header ISA01, Authorization Information Qualifier, Value will be 00. ISA02, Authorization Information, Value will be spaces. ISA03, Security Information Qualifier, Value will be 00. ISA04, Security Information, Value will be spaces. ISA05, Interchange ID Qualifier, Value will be ZZ. ISA06, Interchange Sender ID: Value will be the 7 digit Gainwell assigned Submitter ID (i.e. 450XXXX) followed by spaces. ISA07, Interchange ID Qualifier: Value will be ZZ. ISA08, Interchange Receiver ID: Value will be LA-DHH-MEDICAID. ISA09, Interchange Date: The date format is YYMMDD. ISA10, Interchange Time: The time format is HHMM. ISA 11, Repetition Separator: Value will be ASCIIx5E. ISA12, Interchange Control Version Number: Value will be 00501. ISA13, Interchange Control Number, Value will be identical to the interchange trailer IEA02. Must be a positive unsigned number and must be unique for every transmission submitted. ISA14, Acknowledgment Requested, Value will be 0 or 1. ISA15, Usage Indicator, T Test Data and P Production Data. ISA16, Component Element Separator: Must be a colon: ASCIIx3A. 837 Institutional Companion Guide 11 Interchange Control Trailer IEA01, Number of included Functional Groups. IEA02, Interchange Control Number, Value must be identical to value in ISA13 6.2 GS-GE This section describes Louisiana Medicaid s use of the functional group control segments. Functional Group Header GS01, Functional Identifier Code: Value will be HC for this element. GS02, Application Sender s Code: Value must be identical to ISA06. GS03, Application Receiver s Code: Value will be LA-DHH-MEDICAID. GS04, Date: The date format is CCYYMMDD. GS05, Time: The time format is HHMM. GS06, Group Control Number: Uniquely assigned and maintained by the sender. GS07, Responsible Agency Code: Value will be X. GS08, Version Release Industry Identifier Code: Value will be 005010X223A2. Functional Group Trailer GE01, Number of Transaction Sets included. GE02, Group Control Number; Value must be identical to value in GS06. 6.3 ST-SE This section describes Louisiana Medicaid s use of the transaction set control numbers. ST02, Transaction Set Control Number: Must be identical to associated Transaction Set Control Number SE02. ST03, Implementation Convention Reference: Value will be 005010X223A2. SE02, Transaction Set Control Number: Must be identical to ST02. Only one ST-SE transaction loop is permitted per file. 7. Payer Specific Business Rules and Limitations This section describes Louisiana Medicaid s business rules regarding 837I transactions. 837 Institutional Companion Guide 12 Service line data is required when reporting inpatient, outpatient and home health claims or when payment adjustments (reduction to billed charges or denial) are related to specific claim lines. Since Louisiana Medicaid is a claim line processor, all adjustments are line specific, except for inpatient institutional claims when the per-diem is the only service line adjustment. Each claim line (other than inpatient) will be reported in the 835 as a claim. Data not supplied at the claim level must be supplied at the line level (SVC Service Payment Information). There is a limit of 20,000 CLM segments in a claims file. NOTE: National Provider Identification Numbers are to be submitted in all 837I transactions. Atypical providers who have not registered an NPI with Louisiana Medicaid may continue to submit their legacy Medicaid Provider ID in the 837I as the provider identifier. All successful 837I transactions received prior to cutoff on Thursdays will be processed in a Weekly Adjudication cycle with payment by check or EFT scheduled for the following Tuesday. Exceptions to this schedule will be posted on lamedicaid.com. For Louisiana Medicaid claims, the Patient and the Subscriber are always the same, therefore Patient level data should not be sent. For Louisiana Medicaid s specific business rules and limitations, refer to Section 10 Transaction Set Information, Table 2: 837I Health Claim. Coordination of Benefits (COB)--For the purposes of COB, there are two types of payers in the 837; (1) the destination payer defined in the 2010BB loop, and (2) any other payers defined in the 2330B loop(s). All of the information contained in the 2300 and 2310 loops is specific to the destination payer described in the 2010BB loop. Information specific to other payers is contained in the 2320, 2330, and 2430 loops. Description 837 Loop Segment Data Source Claim Adjustment Group Code Loop 2320 CAS Segment(s) Other Third Party 835 or EOB Payer Paid Amount Loop 2320 AMT D Segment (Qualifier D) Other Third Party 835 or EOB Remaining Patient Liability Loop 2320 AMT EAF Segment (use here when only claim level COB info provided) Calculated by Provider Claim Adjudication Date Loop 2330B DTP Segment Other Third Party 835 or EOB Service Line Paid Amount Loop 2430 SVD Segment Other Third Party 835 or EOB Claim Adjustment Group Code Loop 2430 CAS Segment(s) Other Third Party 835 or EOB Line Adjudication Date Loop 2430 DTP Segment Other Third Party 835 or EOB 837 Institutional Companion Guide 13 Remaining Patient Liability Loop 2430 AMT EAF Segment (Use here when line level COB info provided) Calculated by Provider There may be other payers involved with a claim; therefore, there could be more than 1 set of COB data. If that is the situation, the other Third Party s Louisiana Carrier Code, Paid Amount, Paid Date and CAS Segments would also be reported. Other payers must be identified in the 837 Transaction in Loop 2330B; Segment NM109 with the six- digit Louisiana Medicaid assigned Carrier Code. The Carrier codes may be found on www.lamedicaid.com under the Forms Files Surveys User Manuals link. You may either enter the name of an insurer or download the complete Louisiana Carrier Code listing. 8. Acknowledgements and or Reports HIPAA responses and acknowledgements are available for download via sFTP for a period of 14 days from the original creation date. 8.1 Report Inventory The TA1 notifies the sender that a valid envelope was received or that problems were encountered with the interchange control structure. The TA1 verifies the envelopes only. TA104, Interchange Acknowledgment Code, indicates the status of the interchange control structure. This data element stipulates whether the transmitted interchange was accepted with no errors, accepted with errors, or rejected because of errors. TA105, Interchange Note Code, is a numerical code that indicates the error found while processing the interchange control structure. For a listing and description of TA1 errors, refer to Section 4.6.4 in the HIPAA 5010A EDI General Companion Guide found on lamedicaid.com 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. Reason(s) for failure of claims files will be posted in the 999 which can be retrieved from sFTP. 9. Trading Partner Agreements A Trading Partner Agreement (TPA) is a legal contract between Gainwell, acting on behalf of the State of Louisiana, Department of Health and Hospitals and a provider billing agent clearinghouse health plan, to exchange electronic information. The desire to exchange by and through electronic communications, certain claims and billing information that may contain identifiable financial and or protected health information (PHI) as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 Code of Federal Regulations Parts 160-164, and applicable regulations that implement Title V of the Gramm-Leach-Bliley Act, 15 U.S.C. 6801, et seq. The parties agree to safeguard any and all PHI or other data received, transmitted or accessed electronically to or from each other in accordance with HIPAA. This agreement is within the TPA. 837 Institutional Companion Guide 14 Refer to the Provider Enrollment link on www.lamedicaid.com to obtain information about the TPA forms that are required for enrollment as an electronic claims submitter. 9.1 Trading Partners A Trading Partner is defined as any entity with which Gainwell exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Louisiana Medicaid s Medicaid Management System supports the following categories of Trading Partner: Provider Billing Agency Clearinghouse Health Plan Gainwell will assign Trading Partner IDs (Submitter ID) to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. 10. Transaction Specific Information This section describes the Louisiana Medicaid specific 837 transaction set information requirements, which are outlined in Table 2: 837I Health Claim. The table contains a row for each segment that Louisiana Medicaid has something additional, over and above, the information in the Technical Report Type 3 (TR3). That information can: Limit the repeat of loops, or segments. Limit the length of a simple data element. Specify a sub-set of the Implementation Guides internal code listings. Clarify the use of loops, segments, composite and simple data elements. Any other information tied directly to a loop, segment, composite and or simple data element pertinent to trading electronically with Louisiana Medicaid. 837 Institutional Companion Guide 15 Table 2: 837I Health Claim TR3 Page Loop ID Reference Name Codes Length Notes Comments C.3 HEADER ISA Interchange Control Header ISA Element Separator 1 C.4 ISA06 Interchange Sender ID 7 digit Gainwell assigned Submitter number i.e.450XXXX 15 Enter the Unique Submitter number issued by Gainwell to authorized EDI Submitters followed by spaces Element Separator 1 C.5 ISA08 Interchange Receiver ID LA-DHH- MEDICAID 15 Element Separator 1 C.6 ISA08 Interchange Receiver ID 0 or 1 1 0 No Interchange Acknowledgement Requested 1 Acknowledgement Requested ISA15 Interchange Usage Indicator P or T 1 P Production Data T Test Data Element Separator 1 ISA16 Component Separator: 1 Must be a colon Segment End 1 C.7 HEADER GS Functional Group Header GS Element Separator 1 GS01 Functional Identifier Code HC 2 HC Health Care Claim (837) Element Separator 1 GS02 Application Sender's Code Gainwell assigned Submitter ID 2 15 Value will be identical to value in ISA06 Element Separator 1 GS01 Functional Identifier Code HC 2 HC Health Care Claim (837) 837 Institutional Companion Guide 16 TR3 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 GS02 Application Sender's Code Gainwell assigned Submitter ID 2 15 Value will be identical to value in ISA06 Element Separator 1 GS03 Application Receiver's Code LA-DHH- MEDICAID 2 15 Element Separator 1 GS04 Date CCYYMMDD 8 8 NOTE: Use this date for the functional group creation date. Element Separator 1 C.8 GS05 Time HHMM 4 8 NOTE: Use this time for the creation time. Element Separator 1 GS06 Group Control Number Assigned by Sender 1 9 Uniquely assigned and maintained by the sender Element Separator 1 GS07 Responsible Agency Code X 1 2 X Accredited Standards Committee X12 GS08 Version Release Industry Identifier Code 005010X223A2 1 12 005010X223A2 Standards Approved for Publication by ASC X12 Procedures Review Board 67 HEADER ST Transaction Set Header ST Element Separator 1 ST02 Transaction Set Control Number Assigned by Sender 4 9 NOTE: Must be identical to associated Transaction Set Control Number SE02. Element Separator 1 ST03 Implementation Convention Reference 005010X223A2 1 35 Contains the same value as in GS08. Segment End 1 71 1000A NM1 Submitter Name N1 837 Institutional Companion Guide 17 TR3 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 72 NM109 Identification Code 7 digit Louisiana Medicaid assigned Submitter Number 2 80 Use the 7 digit Louisiana Medicaid Submitter ID assigned by Gainwell (i.e. 450XXXX). Segment End 1 76 1000B NM1 Receiver Name Element Separator 1 NM103 Name Last or Organization Name Receiver Name 1 60 Value is LOUISIANA MEDICAID Element Separator 1 NM109 Identification Code Receiver Code 2 80 Value is LA-DHH- MEDICAID Segment End 1 80 2000A PRV Billing Provider Specialty Information Element Separator 1 PRV01 Provider Code Provider Type Identifier Code 1 3 Value is BI Billing Provider Element Separator 1 PRV02 Reference Identification Qualifier Taxonomy Qualifier Code 2 3 Value is PXC Provider Taxonomy Code Element Separator 1 837 Institutional Companion Guide 18 TR3 Page Loop ID Reference Name Codes Length Notes Comments PRV03 Reference Identification Provider Taxonomy Code 1 50 Value is the taxonomy Codes associated with the NPI of the Billing Provider and registered with Louisiana Medicaid. In situations where a provider may have a single NPI associated with multiple LA Medicaid provider numbers, a tie-breaker such as taxonomy may be required for unique identification of the Medicaid provider ID. Use the same Taxonomy code that was registered with Louisiana Medicaid for the Billing Provider. 84 2010AA NM1 Billing Provider Name If the Billing provider is an atypical provider who has not been issued or registered an NPI with LA Medicaid, DO NOT USE this Loop. Use Loop 2010BB and report legacy Medicaid Provider ID in REF02 with Qualifier G2. Element Separator 1 86 NM108 Identification Code Qualifier Provider Identifier Qualifier Code 1 2 Value is XX NPI (National Provider Identifier) Element Separator 1 NM109 Identification Code Billing Provider NPI Identifier 2 80 Value is the provider NPI registered with Louisiana Medicaid that corresponds to the LA Medicaid provider being reported in this Loop.. If an atypical provider who has registered an NPI with LA Medicaid, report the NPI in this Loop. Segment End 1 837 Institutional Companion Guide 19 TR3 Page Loop ID Reference Name Codes Length Notes Comments 88 2010AA N4 Billing Provider City, State, Zip Code Element Separator 1 89 N403 Postal Code Postal Zip Code 3 15 Value is the 9-digit Zip code. In situations where a provider may have a single NPI associated with multiple LA Medicaid provider numbers, a tiebreaker such as zip code may be required for unique identification of the Medicaid provider ID. Use the same zip code that was registered with Louisiana Medicaid for the Billing Provider. Segment End 1 107 2000B HL Subscriber Hierarchical Level Element Separator 1 108 HL04 Hierarchical Child Code 0 1 1 Value is 0 for this element. For LA Medicaid the subscriber will always equal the patient. Therefore, an additional subordinate HL is not required. Segment End 1 109 2000B SBR Subscriber Information Element Separator 1 110 SBR09 Claim Filling Indicator Code Claim Filing Indicator Code 1 2 Value is MC Medicaid Segment End 1 112 2010BA NM1 Subscriber Name Element Separator 1 NM102 Entity Type Qualifier Entity Type Qualifier 1 1 Value is 1 837 Institutional Companion Guide 20 TR3 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 NM108 Identification Code Qualifier Member ID Qualifier 1 2 Value is MI Member Identification Element Separator 1 NM109 Identification Code 13 digit Louisiana Medicaid Recipient ID Number 2 80 Value is the thirteen digit Medicaid Recipient ID number Segment End 1 122 2010BB NM1 Payer Name Element Separator 1 124 NM108 Identification Code Qualifier Code Qualifier 1 2 Value is PI Payer Identification Element Separator 1 NM109 Identification Code LA-DHH- MEDICAID 2 80 Value is LA-DHH- MEDICAID Segment End 1 129 2010BB REF Billing Provider Secondary Identification This Loop is used by atypical providers that DO NOT have an NPI registered with Louisiana Medicaid. If an atypical provider has an NPI, use Loop 2010AA NM109 REF segment and do not send this REF. Element Separator 1 REF01 Reference Identification Qualifier Reference Qualifier 2 3 Value is G2 Provider Commercial Number Element Separator 1 130 REF02 Reference Identification 7-digit Louisiana Medicaid Provider ID 1 50 Value is the 7 digit Louisiana Medicaid Provider Number Segment End 1 143 2300 CLM Claim Information Element Separator 1 837 Institutional Companion Guide 21 TR3 Page Loop ID Reference Name Codes Length Notes Comments 144 CLM01 Claim Submitter s Identifier Submitter s Claim Identifier Patient Account Number 1 20 Enter a unique number up to 20 characters. Element Separator 1 CLM02 Monetary Amount Billed Charge Amount 2 80 Enter the total charges for the billed services. This amount must be LESS than one million dollars. Element Separator 1 145 CLM05 Health Care Service Location Information CLM05 information applies to all service lines unless over written at the line level. CLM05-1 Facility Code Value First and second positions of the Uniform Bill Type Code 1 2 The following bill type codes are the only ones acceptable for LA Medicaid Inpatient, Outpatient and HH claims plus Managed Care encounters. Use of any other bill type codes will result in claim file rejection. For file extension UB9 use 11,12,13,14,18,21,71,72,76, 81,82,83,85,86,89. For file extension HOM use 32. CLM05-2 Facility Type Code A 1 2 Value is A Uniform Billing Claim Form Bill Type CLM05-3 Claim Frequency Type Code Third position of the UB Bill Type Code 1 1 Value 1 Original claim Value 7 Adjustment of a previous claim Value 8 Void of a previous claim Element Separator 1 153 2300 CL1 Institutional Claim Code Element Separator 1 CL101 Admission Type Code Code indicating admission priority 1 1 Priority of Admission 837 Institutional Companion Guide 22 TR3 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 CL102 Admission Source Code Code indicating admission source 1 1 Point of Origin for Admission Element Separator 1 CL103 Patient Status Code Code indicating patient status 1 2 The patient status as of the statement through date Segment End 1 2300 REF Service Authorization Exception Code Element Separator 1 REF01 Reference Identification Qualifier Reference Qualifier 2 3 Value is 4N Special Payment Reference Number Element Separator 1 REF02 Reference Identification Service Authorization Exception Code 1 50 Value 1 billing for services associated with low level complexity which corresponds to the level of care noted in the definition of Evaluation and Management CPT codes 99281 and 99282 Value 3 billing for services associated with moderate to high level emergency physician care which corresponds to the level of care noted in the definition of Evaluation and Management CPT codes 99283, 99284 and 99285 Segment End 1 2300 REF Prior Authorization Use this Segment if the extended Home Health or Hospice service was prior authorized by Louisiana Medicaid. Element Separator 1 837 Institutional Companion Guide 23 TR3 Page Loop ID Reference Name Codes Length Notes Comments REF01 Reference Identification Qualifier Qualifier Code 2 3 Value is G1 La Medicaid Prior Authorization number Element Separator 1 REF02 Reference Identification Prior Authorization Number 1 50 Value is the Gainwell assigned Prior Authorization Number for the service being billed. Segment End 1 166 2300 REF Payer Claim Control Number Element Separator 1 REF01 Reference Identification Qualifier Qualifier Code 2 3 Value is F8 Original Reference Number Element Separator 1 REF02 Reference Identification Claim Internal Control Number 1 50 Value is the Gainwell assigned 13-digit Internal claim number (ICN). Enter original ICN when billing for adjustment or void of claim. The ICN is required when CLM05-3 value is 7 or 8 Segment End 1 2300 NTE Billing Note Element Separator 1 NTE01 Note Reference Code Qualifier Code 3 3 Value is ADD when this segment sent Element Separator 1 NTE02 Reference Identification Note text 1 80 LA Medicaid no longer requires the Mother s Medicaid ID to be present on baby s claim. Segment End 1 184 2300 HI Principal Diagnosis. Element Separator 1 837 Institutional Companion Guide 24 TR3 Page Loop ID Reference Name Codes Length Notes Comments HI01-01 Code List Qualifier Code Qualifier Code 1 3 Value is ABK for service discharge dates on or after 10 1 2015. Value is BK for service discharge dates prior to 10 1 2015 Element Separator 1 185 HI01-02 Principal Diagnosis Code Diagnosis Code 1 30 Value is the Principal Diagnosis code for the services being billed Element Separator 1 HI01-09 Condition or Response Code N,U,W or Y 1 1 Use the appropriate Present on Admission indicator code as applied to the Principal Diagnosis Segment End 1 187 2300 HI Admitting Diagnosis Element Separator 1 188 HI01-01 Code List Qualifier Code Qualifier Code 1 3 Value is ABJ for admission date on or after 10 1 2015. Value is BJ for admission date prior to 10 1 2015 Element Separator 1 HI01-02 Admitting Diagnosis Code Diagnosis Code 1 30 Value is the patient s diagnosis upon admission to the facility Segment End 1 2300 HI Other Diagnosis Information Enter additional HI Other Diagnosis Segments for conditions that coexist or develop during the patient s treatment. You may enter up to 12 additional diagnosis codes. Element Separator 1 HI01-01 Code List Qualifier Code Qualifier Code 1 3 Code BF Use for service discharge dates before 10 01 2015 Code ABF Use for service discharge dates on or after 10 01 2015 837 Institutional Companion Guide 25 TR3 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 HI01-02 Industry Code Diagnosis Code 1 30 Value is ICD-9 codes for service discharge dates before 10 01 2015; ICD-10 codes for service discharge dates after 10 01 2015 Element Separator 1 HI02-01 Code List Qualifier Code Other Diagnosis Code Qualifier 1 3 BF Use for service discharge dates before 10 01 2015 ABF Use for service discharge dates on or after 10 01 2015 Element Separator 1 HI02-02 Industry Code Other Diagnosis Code 1 30 Value is ICD-9 codes for service discharge dates before 10 01 2015; ICD-10 codes for service discharge dates after 10 01 2015 Element Separator 1 2300 HI Value Information Repeat Value Information segments as needed to report additional Value Codes Element Separator 1 HI01-01 Code List Qualifier Code Qualifier Code 1 3 Value is BE Element Separator 1 HI01-02 Value Code Value Code 2 3 Use code 80 for covered days Code 81 for non-cov days Code 82 for co-insur days Code 83 for Lifetime reserve days Element Separator 1 837 Institutional Companion Guide 26 TR3 Page Loop ID Reference Name Codes Length Notes Comments HI01-05 Value Code Amount Quantity or Dollar Value 1 8 Enter number or dollar value. Values greater than 999 are invalid for Value codes 80, 81, 82 or 83. If required to report Value code 61,enter the MSA or CBSA code (right justified) to the left of the decimal place; cannot exceed 000000.00 Element Separator 1 2300 HI Condition Information Repeat Condition Information Segments as needed to report additional Condition Codes. Element Separator 1 HI01-01 Code List Qualifier Code Qualifier Code 1 3 Value is BG Element Separator 1 HI01-02 Condition Code 1 30 Value is A1 if the service has been rendered as a result of an EPSDT referral. Value is A4 if the service is related to family planning Element Separator 1 319 2310A NM1 Attending Provider Name Effective July 1, 2015, the attending provider is required to be identified. The attending provider in this Loop applies to the entire claim unless overridden at the line level by the presence of Loop 2420C. Attending provider information is required when institutional claims contain any services other than non- scheduled transportation claims. Element Separator 1 837 Institutional Companion Guide 27 TR3 Page Loop ID Reference Name Codes Length Notes Comments NM101 Entity Identifier Code Entity Code 2 3 Value is 71 Element Separator 1 321 NM108 Identification Qualifier Code XX 1 2 Value is XX National Provider Identifier Element Separator 1 NM109 Identification Code NPI of Attending Provider 2 80 Value is the NPI of the attending provider that is registered with the Louisiana Medicaid Program Segment End 1 322 2310A PRV Attending Provider Specialty Information Element Separator 1 PRV01 Provider Code Provider Type Identifier Code 1 3 Value is AT Attending Provider Element Separator 1 PRV02 Reference Identification Qualifier Taxonomy Code Qualifier 2 3 Value is PXC Provider Taxonomy Code Element Separator 1 PRV03 Reference Identification Provider Taxonomy Code 1 50 Value is the taxonomy Code associated with the NPI of the Attending Provider and registered with Louisiana Medicaid. In situations where a provider may have a single NPI associated with multiple LA Medicaid provider numbers, a tie- breaker such as taxonomy may be required for unique identification of the Medicaid provider ID. Use the same Taxonomy code that was registered with Louisiana Medicaid for the Attending Provider. 837 Institutional Companion Guide 28 TR3 Page Loop ID Reference Name Codes Length Notes Comments Segment End 1 324 2310A REF Attending Provider Secondary Identification Element Separator 1 REF01 Reference Identification Qualifier G2 2 3 Value is G2 Provider Louisiana Medicaid Number Element Separator 1 REF02 Reference Identification 7-digit Louisiana Medicaid Provider ID 1 50 Value is the 7-digit Medicaid provider number of an atypical provider who has not registered an NPI with Louisiana Medicaid. Otherwise, do not use this Loop. Segment End 1 349 2310F Referring Provider Name If present, the Referring provider in this Loop applies to the entire claim, unless overridden at the Line level by the presence of Loop 2420D Element Separator 1 350 NM101 Entity Identifier Code Provider Identifier Qualifier Code 2 3 Value is DN Referring Provider Element Separator 1 NM103 Name Last Last name of Referring provider 1 60 Value is the last name of the referring provider Element Separator 1 NM104 Name First First name of Referring Provider 1 36 Value is the first name of the referring provider Element Separator 1 837 Institutional Companion Guide 29 TR3 Page Loop ID Reference Name Codes Length Notes Comments 351 NM108 Identification Code Qualifier Provider Identifier Qualifier Code 1 2 Value is XX National Provider Identifier Element Separator 1 NM109 Identification Code NPI of Referring Provider 2 80 Value is the NPI registered with Louisiana Medicaid that corresponds to the Medicaid provider being reported in this Loop. The Referring Provider must be enrolled in LA. Medicaid. Segment End 1 352 2310F REF Referring Provider Secondary Identification Use this Loop for atypical providers who do not have an NPI. Otherwise, do not use this Loop. Element Separator 1 REF01 Reference Identification Qualifier G2 2 3 G2 Provider Medicaid Number Element Separator 1 REF02 Reference Identification 7-digit Louisiana Medicaid Provider ID 1 50 Value is the 7-digit Medicaid provider number of an atypical provider who has not registered an NPI with Louisiana Medicaid. Segment End 1 354 2320 SBR Other Subscriber Information Repeat if more than one other payer has previously processed the claim. Element Separator 1 356 SBR09 Insurance Type Code 11,12,13,14,15,16, 17,AL,BL,CH,CI, DS,FI,HM,LM,TV, VA,ZZ 1 2 Do NOT use MC for this segment when reporting information about another payer or payers involved in this claim. Use MA when billing Medicare Advantage claims, Use one of the other codes for additional third party coverage. Segment End 1 837 Institutional Companion Guide 30 TR3 Page Loop ID Reference Name Codes Length Notes Comments 358 2320 CAS Claim Level Adjustments Required if other payers are known to be involved in paying on this claim. May repeat up to 6 sets of CAS01 CAS02 groupings. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. Use Loop 2320 only if claim level data is provided by the other payer. If claim line data is available it must be reported in Loop 2430. Element Separator 1 CAS01 Claim Adjustment Group Code CO,CR,OA,PI,PR 1 2 Value is the code received from other payer reported in this Loop. When PR is used, include segments for Deductible, Coinsurance and or Co-payment amounts as appropriate. Element Separator 1 359 CAS02 Claim Adjustment Reason Code Standard Claim Adjustment Reason Code 1 5 Value is CARC code received from other payer reported in this Loop. Element Separator 1 CAS03 Monetary Amount Dollar Value of Adjustment 1 18 Value is the amount of adjustment associated with CAS Code pairing Element Separator 1 384 2330B NM1 Other Payer Name Add information here when another payer has processed the claim before it is sent to Louisiana Medicaid. Repeat Segment if more than one other payer has previously processed the claim. Element Separator 1 837 Institutional Companion Guide 31 TR3 Page Loop ID Reference Name Codes Length Notes Comments NM108 Identification Code Qualifier PI 1 2 Value is PI Payer Identification Segment Separator 1 385 NM109 Identification Code Louisiana Medicaid Carrier Code 6 Value is the 6-digit Louisiana Medicaid Carrier Code for the Payer identified in Loop 2320.The LA Medicaid TPL Carrier Code list can be found on lamedicaid.com under Forms Files User Manuals navigational link. Segment End 1 423 2400 LX Service Line Number The service line number must begin with one and is incremented by 1 for each additional service line. This number can be useful for provider and practice management systems for matching to the electronic remittance advice 835 Transaction. Element Separator 1 LX01 Assigned Number Service Line Number 1 6 Louisiana Medicaid will process and store up to 28 lines for Inpatient claims. Segment End 1 424 2400 SV2 Institutional Service Line Required to specify line level information for institutional claims. Element Separator 1 425 SV204 Unit or Basis of Measurement Code Unit Qualifier Code 2 2 Value is DA Days or UN Units. Element Separator 1 428 SV205 Quantity Service Unit Count 1 4 The maximum length for Louisiana Medicaid for the quantity field is 4 whole numbers. Element Separator 1 837 Institutional Companion Guide 32 TR3 Page Loop ID Reference Name Codes Length Notes Comments 2400 DTP Service Date Element Separator 1 DTP01 Date Time Qualifier Qualifier Code 3 3 Value is 472 Service Date Element Separator 1 DTP02 Date Time Format Qualifier D8, RD8 2 3 Value is D8 CCYYMMDD for single date of service or RD8 CCYYMMDD- CCYYMMDD for range of dates Element Separator 1 DTP03 Date Time Period Date or Time Period 1 35 Service Line Date(s) of service are required on all Outpatient and Home Health claims. Segment End 1 452 2410 LIN Drug Identification A federal statue mandates that providers must report National Drug Code (NDC) information for all physician- administered drugs on LA Medicaid claims submissions. This requirement applies to both electronic and hardcopy claims. Providers are required to submit NDC information for the corresponding HCPCS code for physician- administered drugs. Claims must reflect the NDC from the label of the product administered. Element Separator 1 LIN02 Product Service ID Qualifier Drug Code Qualifier 2 2 Value is N4 National Drug Code in 5-4-2 format. Element Separator 1 837 Institutional Companion Guide 33 TR3 Page Loop ID Reference Name Codes Length Notes Comments LIN03 Product Service ID NDC Code 1 48 Value is the National Drug Code associated with the physician-administered drug identified in Loop 2400 SV202-2. Segment End 1 452 2410 CTP Drug Quantity Quantity and Unit or Basis of Measurement Codes are required for claims for drugs to process correctly. Element Separator 1 CTP04 Quantity Units Administered 1 10 Value is the quantity or actual units administered. The maximum quantity to be entered for LA Medicaid is seven whole numbers and three decimal places. Element Separator 1 453 CTP05-01 Unit or Basis of Measurement Code F2, GE, ME, ML, UN 2 2 F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit Segment End 1 2420C NM1 Rendering Provider Name If present, the rendering provider identified in this Loop applies to the Line Level and overrides the Attending Provider at the Claim Level in Loop 2310A. Element Separator 1 NM101 Entity Identifier Code Qualifier Code 2 3 Value is 82 Rendering Provider NM108 Identification Code Qualifier Provider Identifier Qualifier Code 1 2 Value is XX National Provider Identifier Element Separator 1 837 Institutional Companion Guide 34 TR3 Page Loop ID Reference Name Codes Length Notes Comments NM109 Identification Code National Provider Identification 2 80 Value is the NPI registered with Louisiana Medicaid that corresponds to the Louisiana Medicaid Provider being reported in this Loop. If the provider is considered an atypical provider and has not registered an NPI with Louisiana Medicaid, continue to use Loop 2420C, REF 02 with qualifier G2 to provider the Louisiana Medicaid Provider ID. Segment End 1 2420C REF Rendering Provider Secondary Identification Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. Element Separator 1 REF01 Reference Identification Qualifier G2 2 3 Value is G2 Louisiana Medicaid 7- digit Provider Number. Element Separator 1 REF02 Reference Identification Louisiana Medicaid Provider Number 1 7 If the Rendering Provider is an atypical provider who has not registered an NPI with Louisiana Medicaid, you may send the 7-digit legacy Medicaid Provider number in this Loop. Segment End 471 2420D NM1 Referring Provider Name Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). When billing for services for a Lock-In recipient, identify the Lock- In Physician. 837 Institutional Companion Guide 35 TR3 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 NM101 Entity Identifier Code Referring Provider Qualifier Code 2 3 Value is DN Referring Provider Element Separator 1 NM103 Name Last Referring Provider Last Name 1 60 Value is the last name of the referring provider. Element Separator 1 NM104 Name First Referring Provider First Name 1 35 Value is the first name of the referring provider. Element Separator 1 473 NM108 Identification Code Qualifier Provider Identifier Qualifier Code 1 2 Value is XX National Provider Identifier Element Separator 1 NM109 Identification Code NPI of Referring Provider 2 80 Value is the NPI registered with Louisiana Medicaid that corresponds to the provider being reported in the Loop. The Referring Provider must be enrolled in Louisiana Medicaid. Segment End 474 2420D REF Referring Provider Secondary Identification Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310F). Do not use this Loop if Referring provider has an NPI. Element Separator 1 REF01 Reference Identification Qualifier G2 2 3 Value is G2 Louisiana Medicaid 7- digit Provider Number. Element Separator 1 837 Institutional Companion Guide 36 TR3 Page Loop ID Reference Name Codes Length Notes Comments 475 REF02 Reference Identification Louisiana Medicaid Provider Number 1 7 If the Referring Provider is an atypical provider who has not registered an NPI with Louisiana Medicaid, you may send the 7-digit legacy Medicaid Provider number in this Loop. Segment End 1 476 2430 SVD Line Adjudication Information Required when the claim has been previously adjudicated by payer identified in Loop ID- 2330B and this service line has payments and or adjustments applied to it. Repeat if multiple payers involved. | /kaggle/input/edi-db-835-837/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_0 |
Code 1 2 Value is XX National Provider Identifier Element Separator 1 837 Institutional Companion Guide 34 TR3 Page Loop ID Reference Name Codes Length Notes Comments NM109 Identification Code National Provider Identification 2 80 Value is the NPI registered with Louisiana Medicaid that corresponds to the Louisiana Medicaid Provider being reported in this Loop. If the provider is considered an atypical provider and has not registered an NPI with Louisiana Medicaid, continue to use Loop 2420C, REF 02 with qualifier G2 to provider the Louisiana Medicaid Provider ID. Segment End 1 2420C REF Rendering Provider Secondary Identification Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. Element Separator 1 REF01 Reference Identification Qualifier G2 2 3 Value is G2 Louisiana Medicaid 7- digit Provider Number. Element Separator 1 REF02 Reference Identification Louisiana Medicaid Provider Number 1 7 If the Rendering Provider is an atypical provider who has not registered an NPI with Louisiana Medicaid, you may send the 7-digit legacy Medicaid Provider number in this Loop. Segment End 471 2420D NM1 Referring Provider Name Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). When billing for services for a Lock-In recipient, identify the Lock- In Physician. 837 Institutional Companion Guide 35 TR3 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 NM101 Entity Identifier Code Referring Provider Qualifier Code 2 3 Value is DN Referring Provider Element Separator 1 NM103 Name Last Referring Provider Last Name 1 60 Value is the last name of the referring provider. Element Separator 1 NM104 Name First Referring Provider First Name 1 35 Value is the first name of the referring provider. Element Separator 1 473 NM108 Identification Code Qualifier Provider Identifier Qualifier Code 1 2 Value is XX National Provider Identifier Element Separator 1 NM109 Identification Code NPI of Referring Provider 2 80 Value is the NPI registered with Louisiana Medicaid that corresponds to the provider being reported in the Loop. The Referring Provider must be enrolled in Louisiana Medicaid. Segment End 474 2420D REF Referring Provider Secondary Identification Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310F). Do not use this Loop if Referring provider has an NPI. Element Separator 1 REF01 Reference Identification Qualifier G2 2 3 Value is G2 Louisiana Medicaid 7- digit Provider Number. Element Separator 1 837 Institutional Companion Guide 36 TR3 Page Loop ID Reference Name Codes Length Notes Comments 475 REF02 Reference Identification Louisiana Medicaid Provider Number 1 7 If the Referring Provider is an atypical provider who has not registered an NPI with Louisiana Medicaid, you may send the 7-digit legacy Medicaid Provider number in this Loop. Segment End 1 476 2430 SVD Line Adjudication Information Required when the claim has been previously adjudicated by payer identified in Loop ID- 2330B and this service line has payments and or adjustments applied to it. Repeat if multiple payers involved. Element Separator 1 SVD01 Identification Code Louisiana Medicaid Carrier Code 2 80 Value is the 6-digit Louisiana Medicaid Carrier Code. Number should match NM109 in Loop 2330B identifying the Other Payer. The LA Medicaid TPL Carrier Code list can be found on lamedicaid.com under Forms Files User Manuals navigational link. Element Separator 1 477 SVD02 Monetary Amount Service Line Paid Amount 1 10 Value is the amount Other Payer paid for this service line. Element Separator 1 837 Institutional Companion Guide 37 TR3 Page Loop ID Reference Name Codes Length Notes Comments 480 2430 CAS Line Adjustment Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. Providers are to enter the information as received on the remittance from the Other Payer. Use Loop 2430 only if Line Level data is provided by the other payer. 482 CAS01 Claim Adjustment Group Code CO, OA, PI, PR 1 2 When using Value of PR, include amounts for Deductible, Co-insurance and or Co-Pay as appropriate. Element Separator 1 CAS02 Claim Adjustment Reason Code Claim Adjustment Reason Code 1 5 Value is the CARC code received from the Other Payer for the associated service. Element Separator 1 486 CAS03 Monetary Value Adjustment Amount 1 8 Value is the monetary adjustment amount received from the Other Payer for the associated service. Element Separator 1 488 TRAILER SE Transaction Set Trailer Element Separator 1 SE01 Transaction Segment Count Number 1 10 Value is the total number of Segments included. Element Separator 1 SE02 Transaction Set Control Number Identifying Control Number 4 9 Unique control number and must be identical in ST02 and SE02. Segment End 1 837 Institutional Companion Guide 38 TR3 Page Loop ID Reference Name Codes Length Notes Comments C.9 TRAILER GE Functional Group Trailer Element Separator 1 GE01 Number of Transaction Number 1 6 Value is the number of Transaction sets included. Element Separator 1 GE02 Group Control Number Sender Assigned Number 1 9 Value must be identical to value in GS06. Segment End 1 C.10 TRAILER IEA Interchange Control Trailer Element Separator 1 IEA01 Number of Functional Groups Number 1 5 Value is number of Functional Groups included. Element Separator 1 IEA02 Interchange Control Number Sender Assigned Number 9 9 Value must be identical to value in ISA13. Segment End 1 837 Institutional Companion Guide 39 THIS PAGE INTENTIONALLY LEFT BLANK 837 Institutional Companion Guide 40 Appendices Appendix A Implementation Checklist This appendix contains all necessary steps for submitting receiving electronic transactions with Louisiana Medicaid. Providers must register to become a Trading Partner (TP) and be assigned a TP Submitter number. Trading Partners must sign a Trading Partner Agreement. o Trading Partner must contact the EDI Help Desk by submitting an email to HipaaEDI gainwelltechnologies.com or calling (225) 216-6303 to make arrangements for testing and approval to submit production transactions. Trading Partners must submit two (2) test files of a particular transaction type, with no minimum number of transactions within each file, and have no failures or rejections to be approved to submit production transactions. The test claims should be representative of the type of service you will be providing. Confirm all NPIs used in testing are valid for Louisiana Medicaid and if zip-code or taxonomy are needed as tie-breakers. Review all reports produced by the Gainwell EDI test system. Once TP receives email approval from the EDI Department, may begin submitting claim files to Production environment. Appendix B Business Scenarios and Claim Encounter Example This section describes a few special billing scenarios and transaction examples follow. The first scenario describes the electronic billing to Medicaid for medical services of dual-eligible recipients (i.e., eligible for both Medicare and Medicaid). In situations where Medicare has denied a service which may be covered by Medicaid, the claim may be billed directly to Medicaid. This type of claim will be submitted as a Medicaid claim and not a Medicare crossover. In the past, this type of claim was mandated to be billed hardcopy with the Medicare EOBs attached. The correct placement of the 837I Segments related to Medicare third party information is shown in the scenario 1 examples. The Louisiana Department of Health has identified the unique Louisiana Carrier code for NM109 in the 2330B Loop when reporting the Medicare information as MOL001. The second scenario describes claim examples for billing Medicare Advantage claims electronically. The third scenario describes specific information needed for submitting Subrogation encounters. Only Managed Care Trading Partners are permitted to bill Subrogation type encounters. When a Managed Care Entity (MCE) Member Linkage is retroactively removed and the Member retains Louisiana Medicaid eligibility for the same period, the MCE the Member was linked to may have paid claims for the Member during that period. Retroactive disenrollment may be performed by the Enrollment Broker due to retroactive Medicare coverage changes, the Member opting out of Medical MCE coverage, retroactive linkage of the Member to a Long-Term Care facility or the Program for the All-Inclusive Care for the Elderly (PACE) program. 837 Institutional Companion Guide 41 Any claims already billed to and paid by the MCE during this period would then be excused from the MCEs scope of responsibility. The MCE would be entitled to void any such claims and request the billing provider resubmit their claims to Gainwell for Fee For Service (FFS) Medicaid adjudication and payment. Subrogation outlines the means by which MCEs may submit electronic transactions as a remedy to the covering plan, and to mitigate provider abrasion created by having the biller s previous payment recovered and requesting them to rebill elsewhere. Medicaid Subrogation is a process recognized by CMS and ANSI allowing reimbursement between Payers. Subrogation will allow an MCE previously identified as the payer of last resort for a Member to request reimbursement directly from Gainwell on the basis of encounters previously reported for any such claims paid to the billed provider. This solution provides for direct payment to the MCE without placing any burden of action on the original billing provider. Do not Void the original encounter that is being subrogated. Subrogation requires an original Approved encounter be on file. Rejected or Voided encounters may not be subrogated at this time. 837 Institutional Companion Guide 42 a. Scenario 1 - CLAIMs FOR DUAL MEDICAID MEDICARE ELIGIBLE WHEN DENIED BY MEDICARE The following claim examples are presented as a tool to assist with proper build of electronic 837I for a Dual eligible recipient with Medicare denial information. This example does not represent a complete claim; it gives emphasis to the information needed for identifying the Medicare denial reason(s). Example 1 837I---Inpatient Claim Example for Bill Type 11x (Part A benefits denied by Medicare for Dual Eligible Recipient) NM1 IL 1 SMITH TOM MI 1112233334444 N3 500 MAIN STREET N4 BATON ROUGE LA 70809 DMG D8 19570101 M NM1 PR 2 LOUISIANA MEDICAID PI LA-DHH-MEDICAID N3 4456 SOUTH SHORE BLVD N4 BATON ROUGE LA 444440056 CLM 26407777 9129 11:A:1 A Y Y DTP 096 TM 1625 DTP 434 RD8 20150114-20150118 DTP 435 DT 201501140725 CL1 4 5 01 REF EA A0012345 HI BK:V3001 HI BJ:V3001 HI BF:7728:::::::N HI BE:02:::0 BE:80:::4 HI BG:C1 NM1 71 1 KILDAIRE ROSALYN XX 1234567890 LOOP 2320 SBR P 18 MEDICARE PART A MA Must identify as Medicare Part A CAS PR 258 9129 (Service not covered when person is incarcerated) AMT D 0 AMT EAF 9129 OI Y Y LOOP 2330B NM1 PR 2 Medicare Part A PI MOL001 Must use this Carrier Code N3 PO BOX 12345 N4 Baton Rouge LA 70808 DTP 573 D8 20150527 Loop 2400 LX 1 SV2 0110 3280 DA 4 LX 2 SV2 0250 200 UN 2 LX 3 SV2 0301 1615 UN 9 LX 4 SV2 0311 1133 UN 1 LX 5 SV2 0471 1147 UN 1 LX 6 SV2 0636 1214 UN 2 - --------continue transaction 837 Institutional Companion Guide 43 Example 2: 837I Outpatient Claim example for Bill Type 13x (Part A benefits denied by Medicare for Dual Eligible Recipient.) NM1 IL 1 SMITH JERRY MI 3334455556666 N3 600 MAIN STREET N4 BATON ROUGE LA 70809 DMG D8 19590101 M NM1 PR 2 LOUISIANA MEDICAID PI LA-DHH-MEDICAID N3 4456 SOUTH SHORE BLVD N4 BATON ROUGE LA 444440056 CLM 26407777 1040 13:A:1 A Y Y DTP 096 TM 1625 DTP 434 D8 20150114 DTP 435 DT 201501140725 CL1 4 5 01 REF EA A0012345 HI BK:V3001 HI BJ:V3001 HI BF:7728:::::::N HI BE:02:::0 BE:80:::4 HI BG:C1 NM1 71 1 KILDAIRE BEN XX 1234567890 LOOP 2320 SBR P 18 MEDICARE PART A MA Must identify as Medicare Part A AMT D 0 OI Y Y LOOP 2330B NM1 PR 2 Medicare Part A PI MOL001 Must use this Carrier Code N3 PO BOX 12345 N4 Baton Rouge LA 70808 DTP 573 D8 20150527 Loop 2400 LX 1 SV1 0250 200 UN 2 DTP 472 D8 20140114 Loop 2430 SVD MOL001 0 0250 2 CAS PR 51 200 (These are non-covered services because this is a pre-existing condition) DTP 573 D8 20150301 AMT EAF 200 LX 2 SV1 0320 HC:73060:RT 406 UN 1 DTP 472 D8 20140114 SVD MOL001 0 HC:73060:RT 0320 1 CAS PR 51 406 (These are non-covered services because this is a pre-existing condition) DTP 573 D8 20150301 AMT EAF 406 837 Institutional Companion Guide 44 LX 3 SV1 0450 HC:99283:25 434 UN 1 DTP 472 D8 20140114 SVD MOL001 0 HC:99283:25 0450 1 CAS PR 51 434 (These are non-covered services because this is a pre-existing condition) DTP 573 D8 20150301 AMT EAF 434 - --------continue transaction b. Scenario 2 - CLAIMS FOR RECIPIENTS WITH MEDICARE ADVANTAGE COVERAGE The following claim examples are presented as a tool to assist with proper build of electronic 837I for a Dual eligible recipient with Medicare Advantage coverage. These examples do not represent a complete claim; it gives emphasis to the information needed for identifying the Medicare Advantage Carrier Code and processing details. Example 1 837I ---- Inpatient Claim Example for Bill Type 11x with Medicare Advantage NM1 IL 1 SMITH TOM MI 1112233334444 N3 500 MAIN STREET N4 BATON ROUGE LA 70809 DMG D8 19570101 M NM1 PR 2 LOUISIANA MEDICAID PI LA-DHH-MEDICAID N3 4456 SOUTH SHORE BLVD N4 BATON ROUGE LA 444440056 CLM 26407777 28473.64 11:A:1 A Y Y DTP 096 TM 1625 DTP 434 RD8 20150515-20150520 DTP 435 DT 201505150725 CL1 1 1 01 REF EA A0012345 HI BK:5770 HI BJ:570 HI BF:4561:::::::N HI BE:02:::0 BE:80:::5 HI BG:C1 NM1 71 1 KILDAIRE ROSALYN XX 1234567890 LOOP 2320 SBR P 18 MEDICARE ADVANTAGE PART A MA MUST use code MA for Medicare Advantage Part A CAS CO 45 18320.55 CAS PR 2 875 AMT D 9278.09 AMT EAF 9129 OI Y Y 837 Institutional Companion Guide 45 LOOP 2330B NM1 PR 2 HUMANA PI H19510 Must use the Medicare Advantage Plan Louisiana Carrier Code N3 PO BOX 12345 N4 BATON ROUGE LA 70808 DTP 573 D8 20150603 Loop 2400 LX 1 SV2 0110 3665 DA 5 LX 2 SV2 0250 2637.64 UN 110 LX 3 SV2 0270 1100 UN 20 LX 4 SV2 0300 66 UN 6 LX 5 Thru LX nn - --------continue transaction Example 2 837I---Outpatient Claim example for Bill Type 13x with Medicare Advantage NM1 IL 1 SMITH JERRY MI 3334455556666 N3 600 MAIN STREET N4 BATON ROUGE LA 70809 DMG D8 19590101 M NM1 PR 2 LOUISIANA MEDICAID PI LA-DHH-MEDICAID N3 4456 SOUTH SHORE BLVD N4 BATON ROUGE LA 444440056 CLM 26407777 1377 13:A:1 A Y Y DTP 096 TM 1625 DTP 434 D8 20150323 DTP 435 DT 201503230825 CL1 1 1 01 REF EA A0012345 HI BK:4019 HI BJ:71941 HI BF:2720:::::::N NM1 71 1 KILDAIRE BEN XX 1234567890 LOOP 2320 SBR P 18 MEDICARE PART A MA MUST use code MA for Medicare Advantage Part A AMT D 236.73 OI Y Y 837 Institutional Companion Guide 46 LOOP 2330B NM1 PR 2 HUMANA PI H19510 Must use the Louisiana Medicare Advantage Carrier Code N3 PO BOX 12345 N4 BATON ROUGE LA 70808 DTP 573 D8 20150402 Loop 2400 LX 1 SV2 0250 2 UN 1 DTP 472 D8 20150323 LX 2 SV2 0320 HC:73030:RT 219 UN 1 DTP 472 D8 20150323 LX 3 SV2 0450 HC:99284:25 1113 UN 1 DTP 472 D8 20150323 LX 4 SV2 0730 HC:93005 43 UN 1 DTP 472 D8 20150323 Loop 2430 LX 1 SVD H19510 0 0250 2 CAS CO 45 2 DTP 573 D8 20150323 LX 2 SVD H19510 0 HC:73030:RT 0320 1 CAS CO 45 219 DTP 573 D8 20150323 LX 3 SVD H19510 236.73 HC:99284:25 0450 1 CAS PR 3 65 CAS CO 253 4.83 45 806.44 DTP 573 D8 20150323 LX 4 SVD H19510 0 HC:93005 0730 1 CAS CO 45 43 DTP 573 D8 20150323 - --------continue transaction 837 Institutional Companion Guide 47 Example 3 837I---Inpatient Claim example for Bill Type 11x Medicare Advantage and Other Third Party Coverage NM1 IL 1 SMITH TOM MI 1112233334444 N3 500 MAIN STREET N4 BATON ROUGE LA 70809 DMG D8 19570101 M NM1 PR 2 LOUISIANA MEDICAID PI LA-DHH-MEDICAID N3 4456 SOUTH SHORE BLVD N4 BATON ROUGE LA 444440056 CLM 26407777 28473.64 11:A:1 A Y Y DTP 096 TM 1625 DTP 434 RD8 20150515-20150520 DTP 435 DT 201505150725 CL1 1 1 01 REF EA A0012345 HI BK:5770 HI BJ:570 HI BF:4561:::::::N HI BE:02:::0 BE:80:::5 HI BG:C1 NM1 71 1 KILDAIRE ROSALYN XX 1234567890 LOOP 2320 SBR P 18 MEDICARE ADVANTAGE PART A MA MUST Use code MA for Medicare Advantage Part A CAS CO 45 18320.55 CAS PR 2 875 AMT D 9278.09 AMT EAF 9129 OI Y Y LOOP 2330B NM1 PR 2 HUMANA PI H19510 Must use the Medicare Advantage Plan Louisiana Carrier Code N3 PO BOX 12345 N4 BATON ROUGE LA 70808 DTP 573 D8 20150603 LOOP 2320 SBR S 18 AARP CI Use code CI for Other Private Third Party Coverage CAS CO 45 18320.55 CAS OA 23 9278.09 AMT D 875 AMT EAF 9129 OI Y Y LOOP 2330B NM1 PR 2 AARP Supplement PI 270500 Must use the appropriate LA Medicaid Carrier Code N3 PO BOX 12345 N4 BATON ROUGE LA 70808 DTP 573 D8 20150603 837 Institutional Companion Guide 48 Loop 2400 LX 1 SV2 0110 3665 DA 5 LX 2 SV2 0250 2637.64 UN 110 LX 3 SV2 0270 1100 UN 20 LX 4 SV2 0300 66 UN 6 Thru LX nn -------- continue transaction c. Scenario 3 ENCOUNTERS FOR SUBROGATION The following encounter example is presented as a tool to assist with properly building an 837I for Subrogation. This example does not represent a complete claim; it gives emphasis to the information needed for identifying the encounter as Subrogation. This scenario applies only to Managed Care Trading Partners. Only Managed Care Trading Partners are permitted to bill using Transaction Code 31. See Appendix D for more information. BHT Beginning of Hierarchical Transaction BHT 0019 00 02754534990001 20231110 130010 31 Must use Transaction Type Code 31 LOOP 2010AC NM1 PE 2 MCE ORGANIZATION NAME PI 9999999999 Must include LOOP 2010AC N3 999 STREET ADDRESS This is the Primary Payer Information N4 CITY LA 999999999 REF EI 999999999 LOOP 2300 In Loop ID-2300 data element CLM01, enter the Gainwell assigned CLM 4275127042400 500 11:A:7 Y A ICN number rather than the Provider's Patient Control Number. Y In element CLM05-3 use Claim Frequency Type Code 7: Debit or Replacement adjustment. LOOP 2320 In Loop ID-2320 include all the required segments elements SBR T 18 MC that indicate Gainwell's adjudication of the original encounter.... AMT D 411 AMT02 represents the amount Gainwell reported paid. LOOP 2330B NM1 PR 2 LOUISIANA MEDICAID PI LA-DHH-MEDICAID N4 BATON ROUGE LA 70809 DTP 573 D8 20150527 In Loop ID-2330B, enter Gainwell's information. 837 Institutional Companion Guide 49 Appendix C - Change Summary This appendix will contain a summary of any changes made to this version of the 837I Health Care Claim Companion Guide after the initial release. Ver. Date Author Action Summary of Changes Loop Segment 1.0 01 01 2018 Molina Initial Document in CAQH CORE Master Companion Guide required standard format. Included in this initial release is new information regarding billing for Medicare Advantage claims. Section 4.4.3; Section 10-Segment SBR09; Appendix B Scenario 2 examples 1.2 04 27 2018 Molina Clarification on Medicare Advantage; Claim examples in Appendix B. Loop 2330 SBR09 1.3 02 06 2019 DXC Removed comments regarding of lines for Outpatient claims. Loop 2400 LX01 1.4 2 23 2024 Gainwell Updated Appendix B Scenario 3. Loop 2300, 2320 2040, 2339B 1.5 10 09 2024 Gainwell Revised the Preface to provide a link to the 5010 EDI General Companion Guide. Added link to the 5010 EDI General Companion Guide to 1.1. Corrected the first paragraph of Appendix B for usage issues. Scenario 3 of Appendix B was added (subrogation). Re-designed document for paging issues. Corrected email addresses and links as needed. Appendix D (FAQs) removed. Appendix E renamed Appendix D and sample forms converted to links. n a n a n a n a n a n a n a 1.6 1 14 2025 Gainwell Revised Appendix B Scenario 3. n a 837 Institutional Companion Guide 50 Appendix D - Trading Partner Agreements (TPA) This appendix contains links to the forms required for electronic billing or election to receive an electronic remittance (835) for Louisiana Medicaid providers. There are separate forms for an individual enrollment and an entity business enrollment. Links to the forms are provided below. EDI Contract and Power of Attorney for Individual: https: www.lamedicaid.com Provweb1 Provider_Enrollment EDI 20Individuals.pdf EDI Contract and Power of Attorney for Entity Business: https: www.lamedicaid.com Provweb1 Provider_Enrollment EDI 20Entities-Businesses.pdf Completed forms are to be sent to Gainwell Provider Enrollment Unit, PO Box 80159, Baton Rouge, LA 70898- 0159. | /kaggle/input/edi-db-835-837/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_1 |
HIPAA Transaction Standard Companion Guide Healthcare Claim Payment Advice ASC X12N 835 Version 005010X221A1 for State of Idaho MMIS Date of Publication: 02 29 2024 Document Number: TL419 Version: 11.0 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page ii Revision History Version Date Author Action Summary of Changes 1.0 07 01 2011 Molina Initial document 1.1 09 09 2013 Molina Modified to conform to CAQH CORE standards 1.2 11 11 2013 Molina Updated with DHW requested changes 1.3 01 14 2014 Molina Changed the Data Flow Diagram in Section 4, and added information about Web Services in Section 4 2.0 01 31 2014 TQD DHW approved 1 27 2014 2.1 04 28 2014 J Phillips Added information about sending acknowledgements via Upload and VAN in Section 4 Connectivity with the Payer Communications Process Flows per CR 35250 3.0 05 14 2014 TQD DHW validated 5 5 2014 3.1 05 20 2015 M McFadden Semi-annual review performed made changes 3.2 05 26 2015 Hope McCain Removed references to retired TPA user guides. 4.0 06 15 2015 TQD DHW validated 6 10 2015 4.0 12 22 2015 D Greer Semi-annual review no changes 4.0 5 26 2016 J Phillips Semi-annual review no changes 4.1 12 19 2016 J Richardson Semi-annual review remove secured FTP information and replace with VAN 5.0 1 18 2017 TQD DHW validated 1 12 2017 5.1 6 7 2017 Douglas Greer Semi-annual review minor corrections 6.0 7 27 2017 TQD DHW validated changes 7 27 17 6.1 8 15 2017 Hope McCain Updated for TPA upgrade 6.2 11 22 2017 Hope McCain Additional updates based on State review 7.0 12 1 2017 TQD DHW validated changes 11 30 17 7.0 6 21 2018 J Richardson Semi-annual review no changes 7.1 10 5 2018 M Zampierin Removed Molina reference and replaced with DXC Technology 7.1 11 27 2018 Jimmy Phillips Semi-annual review no changes 7.1 3 1 2019 Jimmy Phillips Semi-annual review no changes 7.1 3 29 2019 Cathy Lavacchia Semi-annual review no changes 7.1 11 27 2019 Jimmy Phillips Semi-annual review no changes 7.2 03 10 2020 Cathy Lavacchia Changed for Rebranding CR 58031 8.0 03 30 2020 TQD Finalized per DHW validated changes. 8.0 4 22 2021 Douglas Greer Semi-annual review no changes 8.1 11 22 2021 Jen Richardson CMS semi-annual review, no content updates. Rebranding changes only. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page iii Version Date Author Action Summary of Changes 9.0 01 21 2022 TQD Finalized for publishing after rebranding 9.0 06 03 2022 Jimmy Phillips Reviewed for semi-annual; no updates necessary. 9.1 08 24 2022 Myranda Payne Clarified Register link location in section 2.2 Trading Partner Registration 10.0 09 30 2022 TQD Finalized per DHW validated changes. 10.0 11 23 2022 Jimmy Phillips Reviewed for semi-annual; no updates necessary. 10.1 05 24 2023 Kelsey Nielsen Changed the sentence "FTP though a secure, dedicated VAN connection." to "FTP through a secure, dedicated VAN connection." 10.2 11 16 2023 Kelsey Nielsen Semi-annual review; Grammatical corrections 10.3 01 25 2024 Jimmy Phillips Changed for Gainwell rebranding project CR 76444 11.0 02 29 2024 TQD Finalized per DHW validated changes. 2020-2024 Gainwell Technologies Company. All rights reserved. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page iv Table of Contents Introduction........................................................................................................ 1 1.1. Scope........................................................................................................... 2 1.2. Overview...................................................................................................... 2 1.3. References.................................................................................................... 2 1.4. Additional Information.................................................................................... 2 Getting Started.................................................................................................... 3 2.1. Working with Gainwell Technologies................................................................ 3 2.2. Trading Partner Registration............................................................................ 3 2.3. Certification and Testing Overview.................................................................... 3 Testing with the Payer.......................................................................................... 3 Connectivity with the Payer Communications Process Flows...................................... 3 4.1. Process Flows................................................................................................ 4 4.2. Transmission Administrative Procedures........................................................... 5 4.3. Re-Transmission Procedure............................................................................. 5 4.4. Communication Protocol Specifications............................................................. 5 4.5. Passwords..................................................................................................... 6 Contact Information............................................................................................. 6 5.1. Gainwell Technologies EDI Helpdesk and EDI Technical Assistance....................... 6 5.2. Provider Service Number................................................................................ 6 5.3. Applicable Websites E-mail.............................................................................. 7 Control Segments and Envelopes.............................................................................. 7 6.1. Delimiters..................................................................................................... 7 6.2. ISA-IEA........................................................................................................ 7 6.3. GS-GE.......................................................................................................... 7 6.4. ST-SE........................................................................................................... 7 Payer-Specific Business Rules and Limitations......................................................... 8 Acknowledgments and or Reports.......................................................................... 8 8.1. Report Inventory (Not Sent for 835 Transactions)............................................. 8 Trading Partner Agreements.................................................................................. 8 Transaction Specific Information......................................................................... 8 Appendices..................................................................................................... 22 Appendix A. Implementation Checklist..................................................................... 22 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 1 of 22 Introduction This section describes how the 5010 X12 Type 3 Technical Reports (TR3) adopted under HIPAA will be detailed using a table. The tables contain a row for each segment where Gainwell Technologies has something additional, over and above the information in the TR3. That information can: Limit the repeat of loops or segments Limit the length of a simple data element Specify a sub-set of the TR3s internal code listings Clarify the use of loops, segments, composite and simple data elements Specify any other information tied directly to a loop, segment, composite, or simple data element pertinent to trading electronically with Gainwell Technologies In addition to the row for each segment, one or more additional rows are used to describe Gainwell Technologies' usage for composite and simple data elements and any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. Page Loop ID Referenc e Name Codes Length Notes Comments 193 2100C NM1 Subscriber Name This row type always indicates that a new segment has begun. It is always shaded at 10, and notes or comments about the segment go in this cell. 195 2100C NM109 Subscriber Primary Identifier 15 This row type exists to limit the length of the specified data element. 196 2100C REF Subscriber Additional 197 2100C REF01 Reference Identification Qualifier 18, 49, 6P, These are the only codes transmitted by Gainwell MS Healthcare. Plan Network Identification Number N6 This row type exists when a note for a particular code value is required. For example, this note may say that value N6 is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it. 218 2110C EB Subscriber Eligibility or Benefit 231 2110C EB13-1 Product Service ID Qualifier AD This row illustrates how to indicate a component data element in the Reference column and specify that only one code value is applicable. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 2 of 22 1.1. Scope This companion guide documents the transaction type listed below and further defines situational and required data elements for processing the 835 healthcare claim payment advice for programs administered by Idaho Medicaid. This document is not the complete EDI transaction format specifications. The complete EDI 835 transaction format can be found in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment Advice (835), as noted in the References section below. Healthcare Claim Payment Advice ASC X12N 835 (005010X221) Addenda Healthcare Claim Payment Advice ASC X12N 835 (005010X221A1) 1.2. Overview Data elements, segments, and loops not included in this guide are not used for processing transactions by Idaho Medicaid but will still be sent if the information is required for compliance with the ASC X12N version 5010A1 format. See the References section below. 1.3. References Please refer to the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment Advice (835) for information not supplied in this document, such as code lists, definitions, and edits. This TR3 Guide can be obtained from the Washington Publishing Company. Their website is https: www.wpc-edi.com. 1.4. Additional Information The CCD and X12 835 TR3 TRN Segment were adopted together as the Federal Healthcare EFT Standards in CMS-0024-IFC: Administrative Simplification: Adoption of Standards for Health Care Electronic Funds Transfers (EFTs) and Remittance Advice. The 835 Healthcare Claim Payment Advice allows automated matchup of claims payment data sent to the Receiver from Idaho Medicaid using computer software. The delivery and use of the 835 Healthcare Claim Payment continues to increase compliance with HIPAA-adopted administrative transactions and encourages entities to use this infrastructure eligibility and claim status. Adoption of the 835 Healthcare Claim Payment Advice simplifies and standardizes information to match the payment to the remittance advice detail, thereby decreasing confusion around electronic funds transfer (EFT) and ERA. Consistent and uniform rules enable providers to match and process both the EFT payment and the v5010 X12 835 and help mitigate: o Unnecessary manual provider follow-up o Faulty electronic secondary billing o Inappropriate write-offs of billable charges o Incorrect billing of patients for co-pays and deductibles o Posting delays And provide for: o Less staff time spent on phone calls and websites o Increased ability to conduct targeted follow-up with health plans and or patients o More accurate and efficient payment of claims If you do not already receive the 835 Healthcare Claim Payment Advice (electronically), please contact the EDI Help Desk today at 1 (866) 686-4272 and select option 2 when prompted for more information. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 3 of 22 Getting Started 2.1. Working with Gainwell Technologies Please visit https: www.idmedicaid.com and click on the Companion Guides link under Reference Material to view the latest versions of this and other X12 Companion Guides. For information on how to use the portal once registered as a trading partner, click the User Guides link under Reference Material. For any questions or to begin testing, contact the Gainwell Technologies EDI Helpdesk at 1 (866) 686-4272 option 2, or e-mail us at idedisupport gainwelltechnologies.com. 2.2. Trading Partner Registration A Trading Partner Account (TPA) is any entity with which Gainwell Technologies exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Gainwell Technologies will assign trading partner IDs to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. To become a trading partner and get your trading partner ID, please visit our website at https: www.idmedicaid.com and click the Register link in the upper right-hand corner of the screen. You may also contact us at 1 (866) 686-4272, option 2. 2.3. Certification and Testing Overview All TPA must be authorized to submit production EDI transactions. Authorization is granted on a per-transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. Any TPA may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Testing with the Payer Trading partners must submit three test files of a particular transaction type, with a minimum of fifteen transactions within each file, and have no failures or rejections to become certified for production. Users will be notified via e-mail and the Trading Partner Status page of the Health PAS website when testing for a particular transaction has been completed. The Trading Partner Status page is found by logging into your trading partner account on the Health PAS website (https: www.idmedicaid.com), hovering over the Account Management tab, and then clicking User Status. Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be found on the Health PAS website under Companion Guides in the 5010 Appendix A Vendor Specs document. Connectivity with the Payer Communications Process Flows Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 4 of 22 4.1. Process Flows Below is the TPA Portal Services Process Flow (Retrieval of an 835 using the TPA Portal Services). Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 5 of 22 Below is the CAQH Web Services Process Flow (Generic Batch Retrieval Request of an 835). 4.2. Transmission Administrative Procedures X12 files (including an acknowledgment of an 835) can be uploaded via the Health PAS website File Exchange X12 Upload. 835 Healthcare Claim Payment Advice transaction files, acknowledgments, and responses to transactions submitted via the Health PAS website can be accessed by selecting Responses under the File Exchange menu. Trading Partners who have established a VAN connection and submitted X12 transactions via the VAN connection may retrieve acknowledgments and responses from their designated VAN Pickup locations. A VAN connection is a secure VPN connection through which X12 files are transferred via the FTP protocol. 4.3. Re-Transmission Procedure ISA13 Interchange Control Number needs to be unique to each file and Trading Partner ID. 4.4. Communication Protocol Specifications The following communications protocols are available for receiving the ASC X12N 835 transaction Files. Batch Mode: HTTPS download via the Health PAS website FTP through a secure, dedicated VAN connection CAQH Web Service: Authorized trading partners can request 835 transactions through CAQH Web Services. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 6 of 22 CAQH Phase III requires that a 999 be returned to the issuer of the 835 to acknowledge receipt and, if appropriate, report errors encountered with the 835 data1. The Gainwell Technologies CAQH Web Services have been enhanced to support this functionality. The CAQH Web Services support two types of transaction protocols: SOAP (Simple Object Access Protocol) and MIME (Multipurpose Internet Mail Extensions). Transactions can be sent through the following links: SOAP Transactions: https: www.idmedicaid.com CAQH_SOAPService SOAPService.svc MIME Transactions: https: www.idmedicaid.com CAQH_MIMEService MIMEService.svc When requesting an 835 using the CAQH Web Services: The PayloadID needs to be set to the Check EFT Payment ID for the desired 835 The PayloadType needs to be specified as X12_835_Request_005010X221A1 The ProcessingMode needs to be set to Batch The requesting Trading Partner ID must match the Receiver ID of the 835 transaction requested When sending a 999 response using the CAQH Web Services: Set the 999 AK102 to the value of the GS06 value for the 835 that the 999 is in response to The PayloadType should be set to X12_999_SubmissionRequest_005010X231A1 The ProcessingMode needs to be set to Batch The following Operations and Messages are supported: Operation Request Response GenericBatchRetrievalRequest GenericBatchRetrievalRequestMessage GenericBatchRetrievalResp onseMessage PayloadReceiptConfirmation PayloadReceiptConfirmationRequestMes sage PayloadReceiptConfirmatio nResponseMessage 4.5. Passwords Trading Partners create their passwords at the time of registration and are required to update them every 60 days per the Health PAS-Online requirements. The password must be at least seven (7) characters long, contain at least one (1) uppercase character, at least one (1) numeral, and at least one (1) special character (!). Contact Information This section contains detailed information concerning EDI Customer Service. 5.1. Gainwell Technologies EDI Helpdesk and EDI Technical Assistance 1 (866) 686-4272 option 2, or e-mail idedisupport gainwelltechnologies.com. 5.2. Provider Service Number 1 (866) 686-4272 option 3, or e-mail idproviderservices gainwelltechnologies.com. 1 Note CAQH has ruled that it is not mandatory for the receiver of an 835 to send a 999. If a 999 is sent, however, the system will accept it for processing. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 7 of 22 5.3. Applicable Websites E-mail The Idaho Medicaid Health PAS website contains companion guides, user guides, and other information needed to download the 835 Healthcare Claim Payment Advice transaction files. Website https: www.idmedicaid.com The e-mail addresses below can be used to contact Idaho Medicaid s EDI Support, Provider Services, and Provider Enrollment departments. These groups can assist and answer questions relating to EDI file submissions, provider enrollment, and services. EDI Support idedisupport gainwelltechnologies.com Provider Services idproviderservices gainwelltechnologies.com Provider Enrollment idproviderenrollment gainwelltechnologies.com Control Segments and Envelopes 6.1. Delimiters Idaho Medicaid does not require specific values for the delimiters used in electronic transactions. The suggested values are included in the specifications below. 6.2. ISA-IEA The following ISA IEA fields are the sender and receiver specific information listed in the 835 transactions. For all other fields, please see the tables below. ISA06 Interchange Sender ID will contain ID_MES_4_MMS_IG ISA08 Interchange Receiver ID will contain the Gainwell Technologies assigned trading partner ID ISA13 Sender generated Interchange Control Number. This number will match the number in IEA02 Please refer to the tables below for the ISA-IEA-specific information for the 835. 6.3. GS-GE The following GS GE fields are the sender and receiver-specific information listed in the 835 transactions. For all other fields, please see the tables below. GS02 Interchange Sender ID will contain ID_MES_4_MMS_IG GS03 Interchange Receiver ID will contain the Gainwell Technologies assigned trading partner ID GS06 Sender generated Group Control Number. Will match the number in GE02 Please refer to the tables below for the GS-GE-specific information for the 835 transactions. 6.4. ST-SE ST02 Sender generated Transaction Set Control Number. Must match the number in SE02 Please refer to the tables below for the ST-SE-specific information for the 835 transactions. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 8 of 22 Payer-Specific Business Rules and Limitations For Gainwell Technologies Healthcare-specific business rules and limitations associated with the ASC X12N 835 Healthcare Claim Payment Advice transaction, please refer to the tables under Section 10 below. Acknowledgments and or Reports The 835 Healthcare Claim Payment Advice transaction files are generated weekly and advise report on claims that are in their finalized status (paid, denied, reversed, etc.). Once generated, the 835 file(s) can be downloaded via the trading partner s site. The following acknowledgments reports related to the submission of EDI transactions by a trading partner are not sent out for 835 transactions. 8.1. Report Inventory (Not Sent for 835 Transactions) TA1 Interchange Acknowledgment. This acknowledgment is sent if requested by setting ISA14 to 1 or if ISA14 is set to 0 and there is an error that needs to be reported 999 Functional Acknowledgment. This acknowledgment file reports any errors found while checking compliance against TR3 specifications or acceptance of an EDI transaction that meets the TR3 specifications 824 Application Advice report This transaction is not mandated by HIPAA, but will be used to report the results of data content edits of transaction sets. It is designed to report rejections based on business rules, such as invalid diagnosis codes, invalid procedure codes, and invalid provider numbers. The 824 Application Advice report does not replace the 999 or TA1 transactions and will only be generated by Health PAS if there are errors within the transaction set BRR Business Rejection Report. Health PAS also produces a readable version of the 824 called the Business Rejection Report (BRR). This report helps to facilitate the immediate correction and re-bill of claims rejected during HIPAA validation Trading Partner Agreements A trading partner agreement is comprised of the completion of the trading partner registration activities and the approval to submit or receive specific transactions. Please refer to Section 2, sub-section Trading Partner Registration, for information on how to register as a trading partner and be authorized to send receive EDI transactions. Transaction Specific Information Listed below in Figure 10-1 are the specific requirements for reading and processing an ASC X12N 835 Healthcare Claim Payment Advice transaction file returned by Gainwell Technologies. Please use these guidelines in conjunction with the official ASC X12N 835 TR3 document to read and process the downloaded 835 Healthcare Claim Payment Advice transaction files. Figure 10-1: 835 Healthcare Claim Payment Advice Page Loop ID Reference Name Codes Length Notes Comments C.3 HEAD ER ISA Interchange Control Header ISA 3 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 9 of 22 Page Loop ID Reference Name Codes Length Notes Comments C.4 ISA01 Authorization Information Qualifier 00 2 Element Separator 1 ISA02 Authorization Information Space Fill 10 Element Separator 1 ISA03 Security Information Qualifier 00 2 Element Separator 1 ISA04 Security Information Not Used - Filled with Spaces 10 Element Separator 1 ISA05 Interchange ID Qualifier ZZ 2 Element Separator 1 ISA06 Interchange Sender ID ID_MES_4_MMS_I G or ID_MMIS_4MOLINA or ID_MMIS_4_DXCM S 15 Element Separator 1 C.5 ISA07 Interchange ID Qualifier ZZ - Mutually Defined 2 Element Separator 1 ISA08 Interchange Receiver ID Gainwell MS assigned Trading Partner ID 15 Gainwell MS assigned at registration C.5 Element Separator 1 ISA09 Interchange Date YYMMDD 6 Element Separator 1 ISA10 Interchange Time HHMM 4 Element Separator 1 ISA11 Repetition Separator 1 Element Separator 1 ISA12 Interchange Version Number 00501 5 Element Separator 1 ISA13 Interchange Control Number Assigned by Sender 9 (must be identical to interchange trailer IEA02) Element Separator 1 C.6 ISA14 Acknowledgment Requested 0 - No Ack. Requested 1 Element Separator 1 ISA15 Usage Indicator P 1 Element Separator 1 ISA16 Component Element Separator: 1 Segment End 1 C.7 GS Functional Group Header GS 2 Element Separator 1 GS01 Functional Identifier Code HP 2 C.7 Element Separator 1 GS02 Application Sender's Code Must be identical to the value in the ISA06 6 Element Separator 1 GS03 Application Receiver's Code Gainwell MS assigned Trading Partner ID 2 15 This is assigned during trading partner registration Element Separator 1 C.8 GS04 Date CCYYMMDD 8 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 10 of 22 Page Loop ID Reference Name Codes Length Notes Comments GS05 Time HHMM 4 8 Time based on a 24- hour clock Element Separator 1 GS06 Group Control Number (Assigned by Sender) Must be identical to the value in the GS02 1 9 Element Separator 1 GS07 Responsible Agency Code X 1 2 Element Separator 1 GS08 Version Release Code 005010X221A1 1 12 Segment End 1 68 ST Transaction Set Header ST 2 Element Separator 1 ST01 Transaction Set Identification Code 835 3 Element Separator 1 ST02 Transaction Set Control Number Sequential number assigned by sender ST02 and SE02 must be identical 4 9 Segment End 1 69 HEAD ER BPR Financial Information BPR 3 70 BPR01 Transaction Handling Code I remittance information only 1 2 Element Separator 1 71 BPR02 Monetary Amount 1 18 Payment amount Element Separator 1 BPR03 Credit Debit Flag code C Credit - payment to the receiver s account 1 Element Separator 1 72 BPR04 Payment Method Code CHK Check BOP Financial Institution Option 3 Payment Format Code 1 10 Element Separator 1 73 BPR06 (DFI)ID Number Qualifier 01 when BPR04 BOP 2 Element Separator 1 BPR07 (DFI) Identification Number 3 12 Required when BPR04 BOP Element Separator 1 74 BPR08 Account Number Qualifier DA - Demand Deposit when BPR04 BOP 1 3 Element Separator 1 BPR09 Account Number Required when BPR04 BOP Element Separator 1 BPR10 Originating Company Identifier 10 Required when BPR04 BOP Element Separator 1 Element Separator 1 75 BPR12 (DFI) ID Number Qualifier 01 - ABATransit Routing Number Including Check Digits when BPR04 BOP 2 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 11 of 22 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 BPR13 (DFI) Identification Number 3 12 Bank Number Element Separator 1 76 BPR14 Account Number Qualifier 1 3 Account Type Element Separator 1 BPR15 Account Number 1 35 Bank Account Number Element Separator 1 BPR16 Date CCYYMMDD 8 EFT or Check Issue Date Segment End 1 77 HEAD ER TRN Reassociation Trace Number TRN 3 Element Separator 1 TRN01 Trace Type Code 1 Current Transaction Trace Number 1 2 Element Separator 1 TRN02 Reference Identification 1 50 Check or EFT Trace Number Element Separator 1 TRN03 Originating Company Identifier 10 Payer Identifier Segment End 1 85 HEAD ER DTM Production Date DTM 3 Element Separator 1 DTM01 Date Time Qualifier 405 Production 3 Element Separator 1 86 DTM02 Date CCYYMMDD 8 Production Date Segment End 1 87 1000A N1 Payer Identification N1 2 Element Separator 1 N101 Entity Identifier Code PR Payer 2 3 Element Separator 1 N102 Name 1 60 Payer Name Segment End 1 89 1000A N3 Payer Address N3 2 Element Separator 1 N301 Address Information Payer Address 1 55 Payer Address Segment Terminator 1 90 1000A N4 Payer City, State, ZIP Code N4 2 Element Separator 1 N401 City Name 2 30 City Element Separator 1 91 N402 State or Province Code 2 State - Required if address is in the United States Element Separator 1 N403 Postal Code 3 15 Zip Code - Required if address is in the United States Segment Terminator 1 94 1000A PER Payer Business Contact Information PER 3 Element Separator 1 95 PER01 Contact Function Code CX Payers Claim Office 2 Element Separator 1 PER02 Name 1 60 Contact Name Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 12 of 22 Page Loop ID Reference Name Codes Length Notes Comments PER03 Communication Number Qualifier TE Telephone 2 Element Separator 1 PER04 Communication Number AAABBBCCCC 1 256 Contact Number Segment End 1 97 1000A PER Payer Technical Contact Information PER 3 Element Separator 1 PER01 Contact Function Code BL Technical Department 2 Element Separator 1 98 PER02 Name 1 60 Contact Name Element Separator 1 PER03 Communication Number Qualifier TE Telephone 2 Element Separator 1 PER04 Communication Number AAABBBCCCC 1 256 Contact Number Segment Terminator 1 102 1000B N1 Payee Identification N1 2 Element Separator 1 N101 Entity Identifier Code PE Payee 2 3 Element Separator 1 N102 Name 1 60 Provider Name Element Separator 1 103 N103 Identification Code Qualifier FI Federal Taxpayer s Identification Number XX Health Care Financing Administration National Provider ID 1 2 Element Separator 1 N104 Identification Code 2 80 Identification Code - NPI or Tax ID Segment Terminator 1 104 1000B N3 Payee Address N3 2 Element Separator 1 N301 Address Information 1 55 Payee Address Line 1 Street, PO Element Separator 1 N302 Address Information 1 55 Address Line 2 - Suite Segment Terminator 1 105 1000B N4 Payee City, State, ZIP Code N4 2 Element Separator 1 N401 City Name 2 30 City Element Separator 1 106 N402 State or Province Code 2 Required if address is in the United States Element Separator 1 N403 Postal Code 3 15 Required if address is in the United States Segment Terminator 1 107 1000B REF Payee Additional identification REF 3 Reference Identification Element Separator 1 REF01 Reference Identification Qualifier TJ SSN FEIN Qualifier, If N103 XX 2 3 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 13 of 22 Page Loop ID Reference Name Codes Length Notes Comments PQ Payee Identification Molina Element Separator 1 108 REF02 Reference Identification 1 50 SSN FEIN (Tax ID) if REF01(1) TJ Segment Terminator 1 111 2000 LX Header Number LX 2 Element Separator 1 LX01 Assigned Number 1 6 Sequential Number Segment Terminator 1 123 2100 CLP Claim Payment Information CLP 3 Claim Level Data CLP01 is from CLM01 of the original claim (generated by the provider) Element Separator 1 CLP01 Claim Submitter s Identifier 1 38 Provider Claim ID (also known as the Patient Control Number) Element Separator 1 124 CLP02 Claim Status Code 1 Paid Primary 2 Paid Secondary 3 Paid Tertiary 4 Denied 22 Reversal 1 2 Element Separator 1 125 CLP03 Monetary Amount 1 18 Billed Amount The billed amount for each claim Element Separator 1 125 CLP04 Monetary Amount 1 18 Paid Amount The dollar amount included in the payment for the claim Element Separator 1 CLP05 Monetary Amount 1 18 Co-Pay Amount Element Separator 1 126 CLP06 Claim Filing Indicator Code MC - Medicaid 1 2 Code Identifying the type of claim Element Separator 1 127 CLP07 Reference Identification 1 50 Claim Internal Control Number (ICN) Element Separator 1 CLP08 Facility Code Value 1 2 Place of Service. Facility Service Code and Claim Frequency Type Code come from CLM05-1 and -2 of 837 Claim Element Separator 1 CLP09 Claim Frequency Type Code 1 Claim Frequency Type Code. Facility Service Code and Claim Frequency Type Code come from CLM05-1 and -2 of 837 Claim Segment Terminator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 14 of 22 Page Loop ID Reference Name Codes Length Notes Comments 129 2100 CAS Claims Adjustment CAS 3 Claim Adjustment (see note at end of CAS segment) Element Separator 1 131 CAS01 Claim Adjustment Group Code CO Contractual Obligations OA Other Adjustments PI Payer Initiated Reduction PR Patient Responsibility 1 2 Element Separator 1 CAS02 Claim Adjustment Reason Code 1 5 First claim adjustment reason code Element Separator 1 132 CAS03 Monetary Amount 1 18 First claim adjustment amount Element Separator 1 Element Separator 1 CAS05 Claim Adjustment Reason Code 1 5 Second claim adjustment reason code Element Separator 1 133 CAS06 Monetary Amount 1 18 Second claim adjustment amount Element Separator 1 Element Separator 1 CAS08 Claim Adjustment Reason Code 1 5 Third claim adjustment reason code Element Separator 1 CAS09 Monetary Amount 1 18 Third claim adjustment amount Element Separator 1 134 Element Separator 1 CAS11 Claim Adjustment Reason Code 1 5 Fourth claim adjustment reason code Element Separator 1 CAS12 Monetary Amount 1 18 Fourth claim adjustment amount Element Separator 1 Element Separator 1 135 CAS14 Claim Adjustment Reason Code 1 5 Fifth claim adjustment reason code Element Separator 1 CAS15 Monetary Amount 1 18 Fifth claim adjustment amount Element Separator 1 Element Separator 1 CAS17 Claim Adjustment Reason Code 1 5 Sixth claim adjustment reason code Element Separator 1 136 CAS18 Monetary Amount 1 18 Sixth claim adjustment amount Segment Terminator 1 Note: Additional CAS segments (up to 99 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 15 of 22 Page Loop ID Reference Name Codes Length Notes Comments total) will be mapped if there are more than six (6) EOB codes passed. 137 2100 NM1 Patient Name NM1 3 Individual or Organizational Name Element Separator 1 NM101 Entity Identifier Code QC Patient Name 2 Element Separator 1 138 NM102 Entity Type Qualifier 1 Person 1 Element Separator 1 NM103 Name, Last or Organization Name 1 60 Client Last Name Required for all claims that are not retail pharmacy claims. Required for retail pharmacy claims when the information is known. Element Separator 1 NM104 Name, First 1 35 Client First Name Required when the patient has a first name, and it is known. Element Separator 1 NM105 Name, Middle 1 25 Client Middle Name Element Separator 1 Element Separator 1 NM107 Name, Suffix 1 10 Client Name Suffix Element Separator 1 139 NM108 Identification Code Qualifier MI Member Identification Number 1 2 Element Separator 1 NM109 Identification Code 2 80 Client Medicaid ID Number Segment Terminator 1 146 2100 NM1 Service Provider Name NM1 3 Element Separator 1 147 NM101 Entity Identifier Code 82 Rendering Provider 2 3 Element Separator 1 NM102 Entity Type Qualifier 1 Person 2 Non-Person 1 Element Separator 1 NM103 Name, Last or Organization Name 1 60 Rendering Provider Last Name Element Separator 1 NM104 Name, First 1 35 Rendering Provider First Name Element Separator 1 148 Element Separator 1 Element Separator 1 Element Separator 1 NM108 Identification code Qualifier XX National Provider ID MC Medicaid Provider Number 1 2 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 16 of 22 Page Loop ID Reference Name Codes Length Notes Comments 149 NM109 Identification Code 2 80 NPI or Provider ID Segment Terminator 1 Note: For TPL Claims: Information for up to three (3) Insurance Companies may be transmitted in N1 segments. If the insurance company name is not available, there will be no NM1 segments for the company. If both the company name and policyholder numbers are not available, neither NM1 segment will be mapped. 153 2100 NM1 Corrected Priority Payer Name NM1 3 Element Separator 1 NM101 Entity Identifier Code PR Payer 2 3 Element Separator 1 154 NM102 Entity Type Qualifier 2 Non-Person Entity 1 Element Separator 1 NM103 Name, Last or Organization Name 1 60 Corrected Priority Payer Name Element Separator 1 Element Separator 1 Element Separator 1 Element Separator 1 Element Separator 1 NM108 Identification code Qualifier PI Payer Identification 1 2 NM109 Identification Code 2 80 Payer Identification Number Segment Terminator 1 173 2100 DTM Statement From or To Date DTM 3 Claim Date Element Separator 1 174 DTM01 Date Time Qualifier 232 From Date of Service 233 To Date of Service 3 Element Separator 1 DTM02 Date CCYYMMDD 8 8 From Date of Service where DTM01 232 To Date of Service where DTM01 233 Segment Terminator 1 175 2100 DTM Coverage Expiration Date DTM 3 Element Separator 1 DTM01 Date Time Qualifier 036 Expiration 3 Element Separator 1 DTM02 Date CCYYMMDD 8 Segment Terminator 1 177 2100 DTM Claim Receive Date DTM 3 Element Separator 1 DTM01 Date Time Qualifier 050 - Received 3 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 17 of 22 Page Loop ID Reference Name Codes Length Notes Comments DTM02 Date CCYYMMDD 8 Segment Terminator 1 184 2100 QTY Claim Supplemental Information Quantity QTY 3 Quantity Gainwell MS uses this segment; ID does not Element Separator 1 QTY01 Quantity Qualifier 2 Element Separator 1 185 QTY02 Quantity 1 15 Segment Terminator 1 186 2110 SVC Service Payment Information SVC 3 187 SVC01-1 Product Service ID Qualifier AD American Dental Association Codes HC HCFA HCPCS Codes N4 National Drug code 5-4-2 format 2 Component Separator: 1 188 SVC01-2 Product Service ID 1 48 Product Service Drug code Component Separator: 1 SVC01-3 Procedure Modifier 2 Modifier-1 Component Separator: 1 189 SVC01-4 Procedure Modifier 2 Modifier-2 Component Separator: 1 SVC01-5 Procedure Modifier 2 Modifier-3 Component Separator: 1 SVC01-6 Procedure Modifier 2 Modifier-4 Element Separator 1 SVC02 Monetary Amount 1 18 Total Charges Billed Element Separator 1 190 SVC03 Monetary Amount 1 18 Provider Payment Amount Element Separator 1 SVC04 Product Service ID 1 48 Revenue Code Element Separator 1 SVC05 Quantity 1 15 Paid Quantity Element Separator 1 Element Separator 1 193 SVC07 Quantity 1 15 Quantity Billed - if different from SVC05 Segment Terminator 1 194 2110 DTM Service Date DTM 3 2110 Element Separator 1 195 DTM01 Date Time Qualifier 150 Service Period Start 151 Service Period End 472 Service (for single-day service) 3 Element Separator 1 DTM02 Date CCYYMMDD 8 Service Date Segment Terminator 1 196 2110 CAS Service Adjustment CAS 3 see note 3 below Element Separator 1 198 CAS01 Claim Adjustment Group Code CO Contractual Obligations OA Other Adjustments 1 2 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 18 of 22 Page Loop ID Reference Name Codes Length Notes Comments PR Patient Responsibility Element Separator 1 CAS02 Claim Adjustment Reason Code 1 5 First claim adjustment reason code Element Separator 1 199 CAS03 Monetary Amount 1 18 First claim adjustment amount Element Separator 1 Element Separator 1 CAS05 Claim Adjustment Reason Code 1 5 Second claim adjustment reason code Element Separator 1 CAS06 Monetary Amount 1 18 Second claim adjustment amount Element Separator 1 200 Element Separator 1 CAS08 Claim Adjustment Reason Code 1 5 Third claim adjustment reason code Element Separator 1 CAS09 Monetary Amount 1 18 Third claim adjustment amount Element Separator 1 Element Separator 1 201 CAS11 Claim Adjustment Reason Code 1 5 Fourth claim adjustment reason code Element Separator 1 CAS12 Monetary Amount 1 18 Fourth claim adjustment amount Element Separator 1 Element Separator 1 202 CAS14 Claim Adjustment Reason Code 1 5 Fifth claim adjustment reason code Element Separator 1 CAS15 Monetary Amount 1 18 Fifth claim adjustment amount Element Separator 1 Element Separator 1 203 CAS17 Claim Adjustment Reason Code 1 5 Sixth claim adjustment reason code Element Separator 1 CAS18 Monetary Amount 1 18 Sixth claim adjustment amount Segment Terminator 1 Note: At a minimum, the Claim Detail CAS segment will contain the Claim Adjustment Group Code (CAS01), Claim Adjustment Code 1 (CAS02), and Adjustment Amount (CAS03). No other fields will be transmitted if there is no data. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 19 of 22 Page Loop ID Reference Name Codes Length Notes Comments Note: A second CAS segment for the Claim Detail will be mapped if more than six (6) detail EOB codes are passed. 204 2110 REF Service Identification REF 3 Element Separator 1 REF01 Reference Identification Qualifier BB Authorization Number 2 3 Element Separator 1 205 REF02 Reference Identification 1 50 Trace Service Line Segment Terminator 1 206 2110 REF Line Item Control Number REF 3 Element Separator 1 REF01 Reference Identification Qualifier 6R Provider Control Number 2 3 Element Separator 1 REF02 Reference Identification 1 50 Line Item Control Number Segment Terminator 1 Note: Second REF segment for Rendering or Attending Provider Information exists and is populated with Medicaid Provider number only when the REF01 value in the previous REF segment is BB and its corresponding REF02 value is equal to a National Provider ID and when a Rendering or Attending Provider Number exists. 209 2110 REF Healthcare Policy Identification REF 3 Element Separator 1 210 REF01 Reference Identification Qualifier 0K Policy Form Identifying Number 2 3 Element Separator 1 REF02 Reference Identification 1 50 Healthcare Policy Identification Segment Terminator 1 211 2110 AMT Service Supplemental Amount AMT 3 Element Separator 1 AMT01 Amount Qualifier Code B6 Allowed Actual 1 3 Element Separator 1 212 AMT02 Monetary Amount 1 18 Amount Allowed Segment Terminator 1 215 2110 LQ Industry Code Health Care Remark Codes LQ 2 Element Separator 1 LQ01 Code List Qualifier Code HE Allowed Actual 1 3 Element Separator 1 216 LQ02 Industry Code 1 30 Remark Code Segment Terminator Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 20 of 22 Page Loop ID Reference Name Codes Length Notes Comments 217 Summ ary PLB Provider Adjustment PLB 3 Transaction Set Trailer Element Separator 1 218 PLB01 Reference Identification 1 50 Provider Number (If the Provider has an NPI, the NPI is used) Summ ary Element Separator 1 PLB02 Date CCYYMMDD 8 Last Day of Current Year Element Separator 1 219 PLB03-1 Adjustment Reason Code 2 Reason Code 1 Component Separator: 1 222 PLB03-2 Reference Identification 1 50 Reference Number 1 May be a Cash Control Number (CCN) or Internal Control Number (ICN) Element Separator 1 223 PLB04 Monetary Amount 1 18 Adjustment Amount 1 This field may also be NEGATIVE PAYMENT due to insufficient positive cash flow Element Separator 1 PLB05-1 Adjustment Reason Code 2 Reason Code 2 Component Separator: 1 PLB05-2 Reference Identification 1 50 Reference number 2 See Reference Number 1 Element Separator 1 224 PLB06 Monetary Amount 1 18 Adjustment Amount 2 See Adjustment Amount 1 Element Separator 1 PLB07-1 Adjustment Reason Code 2 Reason Code 3 Component Separator: 1 PLB07-2 Reference Identification 1 50 Reference number 3 See Reference Number 1 Element Separator 1 PLB08 Monetary Amount 1 18 Adjustment Amount 3 See Adjustment Amount 1 Element Separator 1 225 PLB09-1 Adjustment Reason Code 2 Reason Code 4 Component Separator: 1 PLB09-2 Reference Identification 1 50 Reference number 4 See Reference Number 1 Element Separator 1 PLB10 Monetary Amount 1 18 Adjustment Amount 4 See Adjustment Amount 1 Element Separator 1 PLB11-1 Adjustment Reason Code 2 Reason Code 5 Component Separator: 1 226 PLB11-2 Reference Identification 1 50 Reference number 5 See Reference Number 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 21 of 22 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 PLB12 Monetary Amount 1 18 Adjustment Amount 5 See Adjustment Amount 1 Summ ary Element Separator 1 PLB13-1 Adjustment Reason Code 2 Reason Code 6 Component Separator: 1 PLB13-2 Reference Identification 1 50 Reference number 6 See Reference Number 1 Element Separator 1 227 PLB14 Monetary Amount 1 18 Adjustment Amount 6 See Adjustment Amount 1 Segment Terminator 1 228 TRAIL ER SE Transaction Set Trailer SE 2 3 Element Separator 1 SE01 Number of Included Segments 1 10 Total number of ST through SE segments Element Separator 1 SE02 Transaction Set Control Number 4 9 Assigned by Sender Must be identical to the value in ST02 Segment Terminator 1 C.9 GE Functional Group Trailer GE 2 Element Separator 1 GE01 Number of Transaction Sets Included 1 1 6 Element Separator 1 GE02 Group Control Number 1 9 Assigned by Sender Must be identical to the value in GS06 Segment Terminator 1 C.10 IEA Interchange Control Trailer IEA 3 Element Separator 1 IEA01 Number of Included Functional Groups 1 1 5 Element Separator 1 IEA02 Interchange Control Number 9 Assigned by Sender - Pad Left with Zeros Must be identical to value ISA13 Segment Terminator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 22 of 22 Appendices Appendix A. Implementation Checklist The Trading Partner Account (TPA) User Guide contains information on how to select the correct trading partner entity type and answers some preliminary questions concerning trading partner registration. This guide can be found on the User Guides link under Reference Material on www.idmedicaid.com. | /kaggle/input/edi-db-835-837/CAQH 5010 835 Companion Guide (1).pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_0 |
Centers for Medicare Medicaid Services (CMS) Standard Companion Guide Health Care Claim Institutional (837I) Based on ASC X12N TR3, Version 005010X223A2 Companion Guide Version Number: 8.0, June 2023 CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. ii Disclosure Statement The Centers for Medicare Medicaid Services (CMS) is committed to maintaining the integrity and security of health care data in accordance with applicable laws and regulations. Disclosure of Medicare claims is restricted under the provisions of the Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996. This Companion Guide is to be used for conducting Medicare business only. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. iii Preface This Companion Guide (CG) to the ASC X12N Technical Report Type 3 (TR3) Version 005010 and associated errata adopted under Health Insurance Portability and Accountability Act of 1996 (HIPAA) clarifies and specifies the data content when exchanging transactions electronically with Medicare. Transmissions based on this CG, used in tandem with the TR3, are compliant with both ASC X12N syntax and those guides. This CG is intended to convey information that is within the framework of the TR3 adopted for use under HIPAA. This CG is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the TR3. This CG contains instructions for electronic communications with the publishing entity, as well as supplemental information, for creating transactions while ensuring compliance with the associated ASC X12N TR3s and the Council for Affordable Quality Healthcare Committee on Operating Rules for Information Exchange (CAQH CORE) companion guide operating rules. In addition, this CG contains the information needed by Trading Partners to send and receive electronic data with the publishing entity, who is acting on behalf of CMS, including detailed instructions for submission of specific electronic transactions. The instructional content is limited by ASC X12N s copyrights and Fair Use statement. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. iv Table of Contents Disclosure Statement...............................................................................................................................................ii Preface.................................................................................................................................................................... iii 1 Introduction.................................................................................................................................................... 1 1.1 Scope......................................................................................................................................................... 1 1.2 Overview.................................................................................................................................................... 2 1.3 References................................................................................................................................................. 2 1.4 Additional Information.............................................................................................................................. 3 2 Getting Started................................................................................................................................................ 3 2.1 Working Together...................................................................................................................................... 3 2.2 Trading Partner Registration..................................................................................................................... 3 2.3 Trading Partner Certification and Testing Process.................................................................................... 5 3 Testing and Certification Requirements......................................................................................................... 6 3.1 Testing Requirements................................................................................................................................ 6 3.2 Certification Requirements....................................................................................................................... 7 4 Connectivity Communications...................................................................................................................... 7 4.1 Process Flows............................................................................................................................................. 7 4.2 Transmission.............................................................................................................................................. 8 4.2.1 Re-transmission Procedures............................................................................................................. 8 4.3 Communication Protocol Specifications................................................................................................... 9 4.4 Security Protocols and Passwords............................................................................................................. 9 5 Contact Information........................................................................................................................................ 9 5.1 EDI Customer Service................................................................................................................................ 9 5.2 EDI Technical Assistance.......................................................................................................................... 10 5.3 Trading Partner Service Number............................................................................................................. 10 5.4 Applicable Websites Email.................................................................................................................... 11 6 Control Segments Envelopes...................................................................................................................... 11 6.1 ISA-IEA..................................................................................................................................................... 12 Delimiters Inbound Transactions......................................................................................................... 12 Delimiters Outbound Transactions...................................................................................................... 12 Inbound Data Element Detail and Explanation....................................................................................... 13 6.2 GS-GE....................................................................................................................................................... 13 6.3 ST-SE........................................................................................................................................................ 13 7 Specific Business Rules.................................................................................................................................. 13 7.1 General Notes.......................................................................................................................................... 13 8 Acknowledgments and Reports.................................................................................................................... 14 8.1 Report Inventory..................................................................................................................................... 15 9 Trading Partner Agreement.......................................................................................................................... 15 CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. v 10 Transaction-Specific Information.................................................................................................................. 15 10.1 Header................................................................................................................................................... 15 10.1.1 Header and Information Source................................................................................................... 15 10.1.2 Loop 1000A Submitter Name....................................................................................................... 16 10.1.3 Loop 1000B Receiver Name......................................................................................................... 17 10.2 Billing Provider....................................................................................................................................... 17 10.2.1 Loop 2010AA Billing Provider....................................................................................................... 17 10.3 Subscriber Detail.................................................................................................................................... 17 10.3.1 Loop 2000B Subscriber Hierarchical Level................................................................................... 17 10.3.2 Loop 2010BA Subscriber Name.................................................................................................... 18 10.3.3 Loop 2010BB Payer Name............................................................................................................ 19 10.4 Patient Detail......................................................................................................................................... 20 10.4.1 Loop 2300 Claim Information....................................................................................................... 20 10.4.2 Loop 2310A Attending Provider Name........................................................................................ 21 10.4.3 Loop 2310B Operating Physician Name....................................................................................... 21 10.4.4 Loop 2310C Other Operating Physician Name............................................................................. 21 10.4.5 Loop 2310D Rendering Provider Name........................................................................................ 22 10.4.6 Loop 2310E Service Facility Location........................................................................................... 22 10.4.7 Loop 2310F Referring Provider Name.......................................................................................... 22 10.4.8 Loop 2320 Other Subscriber Information.................................................................................... 23 10.4.9 Loop 2330A Other Subscriber Name............................................................................................ 23 10.4.10 Loop 2330B Other Payer Name.................................................................................................. 24 10.4.11 Loop 2400 Service Line Number................................................................................................. 24 10.4.12 Loop 2410 Drug Identification.................................................................................................... 25 10.4.13 Loop 2420A Operating Physician Name..................................................................................... 26 10.4.14 Loop 2420B Other Operating Physician Name........................................................................... 26 10.4.15 Loop 2420C Rendering Provider Name...................................................................................... 26 10.4.16 Loop 2420D Referring Provider Name....................................................................................... 26 10.4.17 Loop 2430 Line Adjudication Information.................................................................................. 27 10.4.18 Transaction Set Trailer............................................................................................................... 27 11 Appendices.................................................................................................................................................... 28 11.1 Implementation Checklist..................................................................................................................... 28 11.2 Transmission Examples.......................................................................................................................... 28 11.3 Frequently Asked Questions.................................................................................................................. 28 11.4 Acronym Listing..................................................................................................................................... 29 11.5 Change Summary................................................................................................................................... 31 List of Tables Table 1. EDI Transactions and Code Set References............................................................................................... 2 Table 2. Additional EDI Resources.......................................................................................................................... 3 Table 3. ISA Interchange Control Header............................................................................................................. 11 Table 4. CGS Delimiters......................................................................................................................................... 12 CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. vi Table 5. Segment Elements Not Accepted by Medicare.................................................................................... 13 Table 6. Header and Information Source.............................................................................................................. 16 Table 7. Loop 1000A NM1 Submitter Name......................................................................................................... 16 Table 8. Loop 1000B NM1 Receiver Name........................................................................................................... 17 Table 9. Loop 2010AA Billing Provider.................................................................................................................. 17 Table 10. Loop 2000B Subscriber Hierarchical Level............................................................................................ 18 Table 11. Loop 2010BA Subscriber Name............................................................................................................. 18 Table 12. Loop 2010BB Payer Name..................................................................................................................... 19 Table 13. Loop 2300 Claim Information............................................................................................................... 20 Table 14. Loop 2310A Attending Provider Name................................................................................................. 21 Table 15. Loop 2310B Operating Physician Name................................................................................................ 21 Table 16. Loop 2310C Other Operating Physician Name..................................................................................... 21 Table 17. Loop 2310D Rendering Provider Name................................................................................................ 22 Table 18. Loop 2310E Service Facility Location.................................................................................................... 22 Table 19. Loop 2310F Referring Provider Name................................................................................................... 22 Table 20. Loop 2320 Other Subscriber Information............................................................................................. 23 Table 21. Loop 2330A Other Subscriber Name.................................................................................................... 23 Table 22. Loop 2330B Other Payer Name............................................................................................................. 24 Table 23. Loop 2400 Service Line Number........................................................................................................... 24 Table 24. Loop 2410 Drug Identification.............................................................................................................. 25 Table 25. Loop 2420A Operating Physician Name................................................................................................ 26 Table 26. Loop 2420B Other Operating Physician Name..................................................................................... 26 Table 27. Loop 2420C Rendering Provider Name................................................................................................. 26 Table 28. Loop 2420D Referring Provider Name.................................................................................................. 27 Table 29. Loop 2430 Line Adjudication Information............................................................................................ 27 Table 30. Transaction Set Trailer.......................................................................................................................... 27 Table 31. Acronyms Listing and Definitions.......................................................................................................... 29 Table 32. Companion Guide Version History........................................................................................................ 31 CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. vii List of Figures Figure 1. GPNet V5010 Test 837 Claims Transaction Flow..................................................................................... 7 Figure 2. GPNet V5010 837 Claims Transaction Flow............................................................................................. 8 Figure 3. Example of the 837I Control Segments and Envelopes......................................................................... 28 CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 1 1 Introduction This document is intended to provide information from the author of this guide to Trading Partners to give them the information they need to exchange Electronic Data Interchange (EDI) data with the author. This includes information about registration, testing, support, and specific information about control record setup. An EDI Trading Partner is defined as any Medicare customer (e.g., provider supplier, billing service, clearinghouse, or software vendor) that transmits to, or receives electronic data from Medicare. Medicare s EDI transaction system supports transactions adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as well as additional supporting transactions as described in this guide. Medicare Fee-For-Service (FFS) is publishing this Companion Guide (CG) to clarify, supplement, and further define specific data content requirements to be used in conjunction with, and not in place of, the ASC X12N Technical Report Type 3 (TR3) Version 005010 and associated errata mandated by HIPAA and or adopted by Medicare FFS for EDI. This CG provides communication, connectivity, and transaction-specific information to Medicare FFS Trading Partners and serves as the authoritative source for Medicare FFS-specific EDI protocols. Additional information on Medicare FFS EDI practices are referenced within Internet-only Manual (IOM) Pub. 100-04 Medicare Claims Processing Manual: Chapter 24 General EDI and EDI Support, Requirements, Electronic Claims, and Mandatory Electronic Filing of Medicare Claims (https: www.cms.gov Regulations-and- Guidance Guidance Manuals downloads clm104c24.pdf) 1.1 Scope EDI addresses how Trading Partners exchange professional and institutional claims, claim acknowledgments, claim remittance advice, claim status inquiry and responses, and eligibility inquiry and responses electronically with Medicare. This CG also applies to ASC X12N 837I transactions that are being exchanged with Medicare by third parties, such as clearinghouses, billing services or network service vendors. This CG provides technical and connectivity specification for the 837 Health Care Claim: Institutional transaction Version 005010X223A2. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 2 1.2 Overview This CG includes information needed to commence and maintain communication exchange with Medicare. In addition, this CG has been written to assist you in designing and implementing the ASC X12N 837I transaction standard to meet Medicare s processing standards. This information is organized in the sections listed below: Getting Started: This section includes information related to hours of operation, and data services. Information concerning Trading Partner registration and the Trading Partner testing process is also included in this section. Testing and Certification Requirements: This section includes detailed transaction testing information as well as certification requirements needed to complete transaction testing with Medicare. Connectivity Communications: This section includes information on Medicare s transmission procedures as well as communication and security protocols. Contact Information: This section includes EDI customer service, EDI technical assistance, Trading Partner services and applicable websites. Control Segments Envelopes: This section contains information needed to create the Interchange Control Header Trailer (ISA IEA), Functional Group Header Trailer (GS GE), and Transaction Set Header Trailer (ST SE) control segments for transactions to be submitted to or received from Medicare. Specific Business Rules and Limitations: This section contains Medicare business rules and limitations specific to the ASC X12N 837I. Acknowledgments and Reports: This section contains information on all transaction acknowledgments sent by Medicare and report inventory. Trading Partner Agreement: This section contains information related to implementation checklists, transmission examples, Trading Partner Agreements and other resources. Transaction Specific Information: This section describes the specific CMS requirements over and above the information in the ASC X12N 837I TR3. 1.3 References The following locations provide information for where to obtain documentation for Medicare-adopted EDI transactions and code sets. Table 1. EDI Transactions and Code Set References Resource Location ASC X12N TR3s The official ASC X12 website Washington Publishing Company Health Care Code Sets The official Washington Publishing Company website CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 3 1.4 Additional Information The websites in the following table provide additional resources for HIPAA Version 005010A1 implementation: Table 2. Additional EDI Resources Resource Web Address Medicare FFS EDI Operations https: www.cms.gov ElectronicBillingEDITrans 2 Getting Started 2.1 Working Together CGS Administrators, LLC (CGS) is dedicated to providing communication channels to ensure communication remains constant and efficient. CGS has several options to assist the community with their electronic data exchange needs. By using any of these methods CGS is focused on supplying the Trading Partner community with a variety of support tools. An EDI help desk is established for the first point of contact for basic information and troubleshooting. The help desk is available to support most EDI questions incidents while at the same time being structured to triage each incident if more advanced research is needed. Email is also accessible as a method of communicating with CGS EDI. The email account is monitored by knowledgeable staff ready to assist you. When communicating via email, please exclude any protected health information (PHI) to ensure security is maintained. In addition to the CGS EDI help desk and email access, see Section 5 for additional contact information. CGS also has several external communication components in place to reach out to the Trading Partner community. CGS posts all critical updates, system issues and EDI-specific billing material to their website, (https: www.cgsmedicare.com ). All Trading Partners are encouraged to visit this page to ensure familiarity with the content of the site. CGS also distributes EDI pertinent information in the form of an EDI newsletter or comparable publication, which is posted to the website every three months. In addition to the website, a distribution list (https: www.cgsmedicare.com medicare_dynamic ls 001.asp) has been established in order to broadcast urgent messages. 2.2 Trading Partner Registration An EDI Trading Partner is any entity (provider, billing service, clearinghouse, software vendor, employer group, financial institution, etc.) that transmits electronic data to, or receives electronic data from, another entity. Medicare FFS and CGS support many different types of Trading Partners or customers for EDI. To ensure proper registration, it is important to understand the terminology associated with each customer type: CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 4 Submitter the entity that owns the submitter ID associated with the health care data being submitted. It is most likely the provider, hospital, clinic, supplier, etc., but could also be a third party submitting on behalf of one of these entities. However, a submitter must be directly linked to each billing National Provider Identifier (NPI). Often the terms submitter and Trading Partner are used interchangeably because a Trading Partner is defined as the entity engaged in the exchange or transmission of electronic transactions. Thus, the entity that is submitting electronic administrative transactions to CGS is a Medicare FFS Trading Partner. Vendor an entity that provides hardware, software, and or ongoing technical support for covered entities. In EDI, a vendor can be classified as a software vendor, billing or network service vendor, or clearinghouse. Software Vendor an entity that creates software used by Trading Partners to conduct the exchange of electronic transactions with Medicare FFS. Billing Service a third party that prepares and or submits claims for a provider. Clearinghouse a third party that submits and or exchanges electronic transactions (claims, claim status or eligibility inquiries, remittance advice, etc.) on behalf of a provider. Network Service Vendor a third party that provides connectivity between a Trading Partner and CGS. Medicare requires all trading partners to complete an EDI enrollment form and sign an EDI agreement. The EDI enrollment form (https: www.cgsmedicare.com parta edi index.html) designates the Medicare contractor the entity agrees to engage in EDI and ensures agreement between parties to implement standard policies and practices to ensure the security and integrity of the information being exchanged. Entities processing paper do not need to complete an EDI registration. Under HIPAA, EDI applies to all covered entities transmitting the following HIPAA-established administrative transactions: 837I and 837P, 835, 270 271, 276 277, and the National Council for Prescription Drug Programs (NCPDP) D.0. Additionally, Medicare Administrative Contractors (MACs) and Common Electronic Data Interchange (CEDI) will use the Interchange Acknowledgment (TA1), Implementation Acknowledgment (999), and 277 Claim Acknowledgement (277CA) error-handling transactions. Medicare requires that CGS furnish information on EDI to new Trading Partners that request Medicare claim privileges. Additionally, Medicare requires CGS to assess the capability of entities to submit data electronically, establish their qualifications (see test requirements in Section 3), and enroll and assign submitter EDI identification numbers to those approved to use EDI. A provider must obtain an NPI and furnish that NPI to CGS prior to completion of an initial EDI Enrollment Agreement and issuance of an initial EDI number and password by that contractor. CGS is required to verify that NPI is on the Provider Enrollment Chain and Ownership System (PECOS). If the NPI is not verified on the PECOS, the EDI Enrollment Agreement is denied, and the provider is encouraged to contact the appropriate MAC provider enrollment department (for Medicare Part A and Part B provider) or the National Supplier Clearinghouse (for Durable Medical Equipment suppliers) to resolve the issue. Once the NPI is properly verified, the provider can reapply the EDI Enrollment Agreement. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 5 A provider s EDI number and password serve as an electronic signature and the provider would be liable for any improper usage or illegal action performed with it. A provider s EDI access number and password are not part of the capital property of the provider s operation and may not be given to a new owner of the provider s operation. A new owner must obtain their own EDI access number and password. If providers elect to submit receive transactions electronically using a third party such as a billing agent, a clearinghouse, or network services vendor, then the provider is required to have an agreement signed by that third party. The third party must agree to meet the same Medicare security and privacy requirements that apply to the provider in regard to viewing or using Medicare beneficiary data. These agreements are not to be submitted to Medicare but are to be retained by the provider. Providers will notify CGS which third party agents they will be using on their EDI Enrollment form. Third parties are required to register with CGS by completing the third-party agreement form. This will ensure that their connectivity is completed properly, however they may need to enroll in mailing lists separately in order to receive all publications and email notifications. Additional third-party billing information can be found at (https: www.cgsmedicare.com parta edi enrollment.html). The providers must also be informed that they are not permitted to share their personal EDI access number and password with any billing agent, clearinghouse, or network service vendor. Providers must also not share their personal EDI access number with anyone on their own staff who does not need to see the data for completion of a valid electronic claim, to process a remittance advice for a claim, to verify beneficiary eligibility, or to determine the status of a claim. No other non-staff individuals or entities may be permitted to use a Provider s EDI number and password to access Medicare systems. Clearinghouse and other third-party representatives must obtain and use their own unique EDI access number and password from CGS. For a complete reference to security requirements, see Section 4.4. 2.3 Trading Partner Certification and Testing Process Medicare FFS requires all Trading Partners to send a test file containing at least 25 claims, which are representative of their practice or services. To begin the testing and certification process, trading partners should complete the J15 Communications and the enrollment form (https: www.cgsmedicare.com parta edi enrollment.html). Once CGS provides the Submitter ID to a trading partner a test file should be submitted to CGS containing at least 25 claims with a T in the ISA15. Description of delivery and interpretation of results. Once the test file is submitted, verify the file received an accepted 999 and 277CA. Once an error free 277CA populates the EDI helpdesk should be contacted to move the submitter ID into production. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 6 3 Testing and Certification Requirements 3.1 Testing Requirements All submitters must produce accurate electronic test files before being allowed to submit claim transactions in production. Test claims are subject to ASC X12N standard syntax and TR3 semantic data edits. Documentation will be provided when this process detects errors. Standard syntax testing validates the programming of the incoming file and includes file layout, record sequencing, balancing, alpha-numeric numeric date file conventions, field values, and relational edits. Test files must pass 100 percent of the standard syntax tests before submission to production is approved. TR3 Semantic Data testing validates data required for claims processing, e.g., procedure diagnosis codes, modifiers. A submitter must demonstrate, at a minimum, 95 percent accuracy rate in data testing before submission in production is approved where, in the judgment of CGS, the vendor submitter will make the necessary correction(s) prior to submitting a production file. For MACs, the minimum 95 percent accuracy rate includes the front-end edits applied implementation guide editing module (https: www.cgsmedicare.com parta edi index.html). o Test results will be provided to the submitter within three business days; during HIPAA version transitions this time period may be extended, not to exceed ten business days. Many submitters use the same software, or the same clearinghouse to submit their electronic transactions to Medicare. Once a vendor or clearinghouse passes the testing process, clients of that entity using the approved software will not be required to test prior to being migrated to production. If a vendor or clearinghouse supports multiple software products, each product will require testing. Third party agents who have passed testing will be required to provide CGS with their client migration schedule. Trading Partners who submit transactions directly to more than one A B MAC must contact each A B MAC with whom they exchange EDI transactions to inquire about the need for supplemental testing whenever they plan to begin to use an additional EDI transaction, different or significantly modified software for submission of a previously used EDI transaction, or before a billing agent or clearinghouse begins to submit transactions on behalf of an additional Trading Partner. The individual A B MAC may need to retest at that time to re- establish compatibility and accuracy, particularly if there will also be a change in the telecommunication connection to be used. Billing services and clearinghouses are not permitted to begin to submit or receive EDI transactions on behalf of a Provider prior to submission of written authorization by the Trading Partner that the billing agent or clearinghouse has been authorized to handle those transactions on the provider s behalf. See Section 2.2 for further information on EDI enrollment. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 7 3.2 Certification Requirements Medicare FFS does not certify Trading Partners. However, CGS does certify vendors, clearinghouses, and billing services by conducting testing with them and maintaining an approved vendor list. Part A Approved Vendor List (https: www.cgsmedicare.com parta edi index.html) Home Health Hospice Vendor List (https: www.cgsmedicare.com hhh edi index.html) 4 Connectivity Communications 4.1 Process Flows The following diagram illustrates how ANSI ASC X12 electronic transactions flow into and out of GPNet, CGS Palmetto GBA s EDI Gateway. Figure 1. GPNet V5010 Test 837 Claims Transaction Flow CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 8 Figure 2. GPNet V5010 837 Claims Transaction Flow 4.2 Transmission Please see the GPNet Communications Manual and Connectivity Specifications posted under Manuals and User Guides (https: www.cgsmedicare.com parta edi manuals.html) 4.2.1 Re-transmission Procedures CGS does not require any identification of a previous transmission of a claim. All claims should be marked as original. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 9 4.3 Communication Protocol Specifications Please see the GPNet Communications Manual posted under Manuals and User Guides (https: www.cgsmedicare.com parta edi manuals.html) Note: Internet connectivity is only available using our CAQH CORE connectivity method for the following transactions: 276: ASC X12 Health Care Claim Status Request 277: ASC X12 Health Care Information Status Notification 835: ASC X12 Health Care Claim Payment Advice 999: ASC X12 Implementation Acknowledgment For Health Care Insurance Under the internet portal demonstration, for select transaction and with prior CMS approval 4.4 Security Protocols and Passwords All Trading Partners must adhere to CMS information security policies; including, but not limited to, the transmission of electronic claims, claim status, receipt of the remittance advice, or any system access to obtain beneficiary PHI and or eligibility information. Violation of this policy will result in revocation of all methods of system access. CGS is responsible for notifying all affected Trading Partners as well as reporting the system revocation to CMS. Password guidelines are provided with receipt of initial passwords from CGS. Please contact the EDI helpdesk for assistance with passwords and resets CMS information security policy strictly prohibits the sharing or loaning of Medicare assigned IDs and passwords. Users should take appropriate measures to prevent unauthorized disclosure or modification of assigned IDs and passwords. The Trading Partner should protect password privacy by limiting knowledge of the password to key personnel. The password should be changed when there are any personnel changes. The submitter ID and Password are required to transmit files to CGS. 5 Contact Information 5.1 EDI Customer Service J15- Part A Home Health Hospice (HHH) Correspondence CGS PO box 20018 Nashville, TN 37202 CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 10 EDI Helpdesk Numbers CGS Part A 1-866-590-6703 Option 2 CGS Part B 1-866-276-9558 Option 2 CGS HHH 1-866-299-4500 Option 2 EDI Fax Numbers Ohio Part A 1-615-664-5945 Kentucky Part A 1-615-664-5943 Ohio Part B 1-615-664-5927 Kentucky Part B 1-615-664-5917 Home Health Hospice 1-615-664-5947 Hours of Operation and Holiday Schedule Monday Friday 8:00 a.m. to 5:00 p.m. Eastern Time. CGS Holiday Schedule New Year s Day Martin Luther King, Jr. s Birthday Memorial Day Independence Day Labor Day Thanksgiving Day Day after Thanksgiving Christmas Eve Christmas Day 5.2 EDI Technical Assistance See section 5.1 for Technical Assistance Information 5.3 Trading Partner Service Number See section 5.1 for Technical Assistance Information CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 11 5.4 Applicable Websites Email CGS Medicare Part B Online Help (https: www.cgsmedicare.com partb cs online_help.html) CGS Home Health Hospice Online Help (https: www.cgsmedicare.com hhh cs onlinehelphhh.html) CGS Medicare Part A Online Help (https: www.cgsmedicare.com parta cs online_help.html) CGS Medicare Website (http: www.cgsmedicare.com) 6 Control Segments Envelopes Enveloping information must be as follows: Note: A hyphen in the table below means N A. Table 3. ISA Interchange Control Header Page Element Name Codes Content Notes Comments C.4 ISA01 Authorization Information Qualifier 00 Medicare expects the value to be 00. C.4 ISA02 Authorization Information - ISA02 shall contain 10 blank spaces. C.4 ISA03 Security Information Qualifier 00 Medicare expects the value to be 00 and ISA04 shall contain 2 blank spaces. C.4 ISA04 Security Information - Medicare does not use Security Information and will ignore content sent in ISA04. C.4 ISA05 Interchange ID Qualifier 28, ZZ Must be 28 or ZZ C.4 ISA06 Interchange Sender ID - Each MAC will assign its own ID. This is also required in the GS02. C.5 ISA07 Interchange ID Qualifier 28, ZZ Must be 28 or ZZ C.5 ISA08 Interchange Receiver ID - Medicare Administrative Contractor (MAC) contract number for the inbound transactions. Ohio Part A 15201 Kentucky Part A 15101 Home Health Hospice 15004 CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 12 Page Element Name Codes Content Notes Comments C.5 ISA11 Repetition Separator - CGS repetition separator character. C.6 ISA14 Acknowledgement Requested 1 Medicare requires submitter to send code value 1 Interchange Acknowledgment Requested (TA1). Medicare will only return a TA1 segment when there is an error in the ISA IEA Interchange Envelope. C.7 GS02 Application Sender Code - Submitter number assigned by CGS C.7 GS03 Application Receiver s Code - CGS contract number. C.7 GS04 Functional Group Creation Date - Must not be a future date C.7 GS08 Version Identifier Code 005010X223A2 Medicare expects value 005010X223A2 Interchange Control (ISA IEA), Functional Group (GS GE), and Transaction Set (ST SE) envelopes must be used as described in the TR3. Medicare s expectations for the Control Segments and Envelopes are detailed in Sections 6.1, 6.2, and 6.3. 6.1 ISA-IEA Delimiters Inbound Transactions As detailed in the TR3, delimiters are determined by the characters sent in specified, set positions of the ISA header. For transmissions inbound to Medicare FFS, these characters are determined by the submitter and can be any characters as defined in the TR3 and must not be contained within any data elements within the ISA IEA Interchange Envelope. Delimiters Outbound Transactions Trading Partners should contact CGS for a list of delimiters to expect from Medicare. Note that these characters will not be used in data elements within an ISA IEA Interchange Envelope. Table 4. CGS Delimiters Delimiter Character Used Dec Value Hex Value Data Element Separator 42 2A Repetition Separator 94 5E CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 13 Delimiter Character Used Dec Value Hex Value Component Element Separator 62 3E Segment Terminator 126 7E Inbound Data Element Detail and Explanation All data elements within the ISA IEA interchange envelope must follow ASC X12N syntax rules as defined within the TR3. 6.2 GS-GE Functional group (GS-GE) codes are transaction specific. Therefore, information concerning the GS GE Functional Group Envelope can be found in Table 3. 6.3 ST-SE Medicare FFS follows the HIPAA-adopted TR3 requirements. 7 Specific Business Rules This section describes the specific CMS requirements over and above the standard information in the TR3. 7.1 General Notes Errors identified for business level edits performed prior to the Subscriber loop (2000B) will result in immediate file failure at that point. When this occurs, no further editing will be performed beyond the point of failure. The billing provider must be associated with an approved electronic submitter. Claims submitted for billing providers that are not associated to an approved electronic submitter will be rejected. The following table describes segments elements not accepted by Medicare. Note: A hyphen in the table below means N A. Table 5. Segment Elements Not Accepted by Medicare Page Loop ID Reference Name Codes Content Notes Comments 81 2000A CUR Foreign Currency Information - Medicare does not support the submission of foreign currency. 99 2010AC Loop Rule Pay to Plan Loop - Must not be present. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 14 Page Loop ID Reference Name Codes Content Notes Comments 120 2010BA REF Subscriber Secondary Identification (REF01 SY ) - Must not be present. 127 2010BB REF Payer Secondary Identification - Must not be present. 131 2000C Loop Rule Patient Hierarchical Level - Must not be present. For Medicare, the subscriber is always the same as the patient. 158 2300 CN1 Contract Information - Must not be present. 396 2330C Loop Rule Other Payer Attending Provider - Must not be present. 400 2330D Loop Rule Other Payer Operating Physician - Must not be present. 404 2330E Loop Rule Other Payer Other Operating Physician - Must not be present. 408 2330F Loop Rule Other Payer Service Facility Location - Must not be present. 412 2330G Loop Rule Other Payer Rendering Provider Name - Must not be present. 416 2330H Loop Rule Other Payer Referring Provider - Must not be present. 420 2330I Loop Rule Other Payer Billing Provider - Must not be present. 8 Acknowledgments and Reports CGS will provide acknowledgments and reports for submitted X12 version 005010 transactions. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 15 Medicare has adopted three acknowledgement transactions with the Version 005010 implementation: the 277CA, the TA1, and the 999. These acknowledgments will replace proprietary reports previously provided by the MACs. Medicare FFS has adopted a process to only reject claim submissions that are out of compliance with the ASC X12N Version 005010 standard; the appropriate response for such errors will be returned on a 999. Batch submissions with errors will not be rejected in totality, unless warranted. 8.1 Report Inventory CGS does not provide any proprietary acknowledgments. 9 Trading Partner Agreement EDI Trading Partner Agreements ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. Medicare FFS requires all Trading Partners to sign a Trading Partner Agreement with CGS. This agreement can be found on the CGS website (https: www.cgsmedicare.com parta edi index.html). Additionally, CGS requires the following: The CGS Trading Partner Agreement process is identical to our EDI enrollment and registration process. 10 Transaction-Specific Information This section defines specific CMS requirements over and above the standard information in the ASC X12N 837I TR3. 10.1 Header The following sub-sections contain specific details associated with header. 10.1.1 Header and Information Source The following tables define the specific details associated with Header and Information Source: Note: A hyphen in the table below means N A. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 16 Table 6. Header and Information Source Page Loop ID Reference Name Codes Content Length Notes Comments 67 - ST02 Transaction Set Control Number - 9 The MAC will reject an interchange (transmission) that is not submitted with unique values in the ST02 (Transaction Set Control Number) elements. 68 - BHT02 Transaction Set Purpose Code 00 2 Must equal 00 (ORIGINAL). 69 - BHT06 Claim Encounter Identifier CH 2 Must equal CH (CHARGEABLE). 10.1.2 Loop 1000A Submitter Name The following table defines the specific details associated with Loop 1000A Submitter Name: Note: A hyphen in the table below means N A. Table 7. Loop 1000A NM1 Submitter Name Page Loop ID Reference Name Codes Content Length Notes Comments 72 1000A NM105 Submitter Middle Name or Initial - 25 The first position must be alphabetic (A-Z). 72 1000A NM109 Submitter ID - 80 The MAC will reject an interchange (transmission) that is submitted with a submitter identification number that is not authorized for electronic claim submission. Submitter ID must match the value submitted in ISA06 and GS02. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 17 10.1.3 Loop 1000B Receiver Name The following table defines the specific details associated with Loop 1000B Receiver Name: Note: A hyphen in the table below means N A. Table 8. Loop 1000B NM1 Receiver Name Page Loop ID Reference Name Codes Content Length Notes Comments 77 1000B NM103 Receiver Name - 60 - 77 1000B NM109 Receiver Primary Identifier - 80 The MAC will reject an interchange (transmission) that is not submitted with a valid Part A MAC code. Each individual MAC determines this identifier. Submitter ID must match the value submitted in ISA08 and GS03. 10.2 Billing Provider 10.2.1 Loop 2010AA Billing Provider The following table defines the specific details associated with Loop 2010AA Billing Provider: Note: A hyphen in the table below means N A. Table 9. Loop 2010AA Billing Provider Page Loop ID Reference Name Codes Content Length Notes Comments 89 2010AA N403 Billing Provider Postal Code - 15 When the postal code does not include a 4 value, use 9998. 10.3 Subscriber Detail The following sub-sections contain specific requirements for the Subscriber Detail. 10.3.1 Loop 2000B Subscriber Hierarchical Level The following table defines the specific details associated with Loop 2000B Subscriber Hierarchical Level. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 18 Table 10. Loop 2000B Subscriber Hierarchical Level Page Loop ID Reference Name Codes Content Length Notes Comments 108 2000B HL04 Hierarchical Child Code 0 1 The value accepted is 0. 109 2000B SBR01 Payer Responsibilit y Sequence Number Code P, S, T 1 The values accepted are P or S or T. 110 2000B SBR02 Individual Relationship Code 18 2 For Medicare, the subscriber is always the same as the patient. 110 2000B SBR09 Claim Filing Indicator Code MA 2 For Medicare, the subscriber is always the same as the patient. 10.3.2 Loop 2010BA Subscriber Name The following table defines the specific details associated with Loop 2010BA Subscriber Name. Note: A hyphen in the table below means N A. Table 11. Loop 2010BA Subscriber Name Page Loop ID Reference Name Codes Content Length Notes Comments 113 2010BA NM102 Subscriber Entity Type Qualifier 1 1 The value accepted is 1. 113 2010BA NM105 Subscriber Middle Name or Initial - 25 The first position must be alphabetic (A-Z). 114 2010BA NM108 Subscriber Identification Code Qualifier MI 2 The value accepted is MI. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 19 Page Loop ID Reference Name Codes Content Length Notes Comments 114 2010BA NM109 Subscriber Primary Identifier - 80 The MBI: must be 11 positions in the format of C A AN N A AN N A A N N where C represents a constrained numeric 1 thru 9, A represents alphabetic character A Z but excluding S, L, O, I, B, Z, N represents numeric 0 thru 9, and AN represents either A or N. 118 2010BA DMG02 Subscriber Birth Date - 35 Must not be a future date. 10.3.3 Loop 2010BB Payer Name The following table defines the specific details associated with Loop 2010BB Payer Name. Table 12. Loop 2010BB Payer Name Page Loop ID Reference Name Codes Content Length Notes Comments 113 2010BB NM108 Payer Identification Code Qualifier PI 2 The value accepted is PI. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 20 10.4 Patient Detail The following sub-sections contain specific details associated with Patient Detail. 10.4.1 Loop 2300 Claim Information The following tables define the specific details associated with Loop 2300 Claim Information. Note: A hyphen in the table below means N A. Table 13. Loop 2300 Claim Information Page Loop ID Reference Name Codes Content Length Notes Comments 144 2300 CLM01 Patient Control Number - 38 Only 20 characters will be stored and returned by Medicare. 145 2300 CLM02 Total Claim Charge Amount - 10 When Medicare is primary payer, CLM02 must equal the sum of all SV203 service line charge amounts. When Medicare is Secondary or Tertiary payer, Total Submitted Charges (CLM02) must equal the sum of all 2320 2430 CAS amounts and the 2320 AMT02 (AMT01 D ). 147 2300 CLM20 Delay Reason Code - 2 Data submitted in CLM20 will not be used for processing. 148 2300 DTP03 Admission Date - - Must not be a future date. 149 2300 DTP03 Discharge Hour - - Must be in format HHMM.MM - 2300 PWK Claim Supplement Information - - Only the first iteration of the PWK, at either the claim level and or line level, will be considered in the claim adjudication. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 21 Page Loop ID Reference Name Codes Content Length Notes Comments 156 2300 PWK02 Attachment Transmission Code BM, FX, FT, EL 2 Must be BM, FX, FT, or EL. 10.4.2 Loop 2310A Attending Provider Name The following tables define the specific details associated with Loop 2310A Attending Provider Name. Note: A hyphen in the table below means N A. Table 14. Loop 2310A Attending Provider Name Page Loop ID Reference Name Codes Content Length Notes Comments 320 2310A NM105 Attending Provider Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.3 Loop 2310B Operating Physician Name The following table defines the specific details associated with Loop 2310B Operating Physician Name. Note: A hyphen in the table below means N A. Table 15. Loop 2310B Operating Physician Name Page Loop ID Reference Name Codes Content Length Notes Comments 327 2310B NM105 Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.4 Loop 2310C Other Operating Physician Name The following table defines the specific details associated with Loop 2310C Other Operating Physician Name. Note: A hyphen in the table below means N A. Table 16. Loop 2310C Other Operating Physician Name Page Loop ID Reference Name Codes Content Length Notes Comments 332 2310C NM105 Other Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 22 10.4.5 Loop 2310D Rendering Provider Name The following table defines the specific details associated with Loop 2310D Rendering Provider Name. Note: A hyphen in the table below means N A. Table 17. Loop 2310D Rendering Provider Name Page Loop ID Reference Name Codes Content Length Notes Comments 337 2310D NM105 Rendering Provider Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.6 Loop 2310E Service Facility Location The following table defines the specific details associated with Loop 2310E Service Facility Location. Note: A hyphen in the table below means N A. Table 18. Loop 2310E Service Facility Location Page Loop ID Reference Name Codes Content Length Notes Comments 346 2310E N403 Service Facility Location Postal Code - 15 When the postal code does not include a 4 value, use 9998. 10.4.7 Loop 2310F Referring Provider Name The following table defines the specific details associated with Loop 2310F Referring Provider Name. Note: A hyphen in the table below means N A. Table 19. Loop 2310F Referring Provider Name Page Loop ID Reference Name Codes Content Length Notes Comments 350 2310F NM105 Referring Provider Middle Name - 25 The first position must be alphabetic (A-Z). 352 2310F REF Referring Provider Name Secondary Identification - - Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 23 10.4.8 Loop 2320 Other Subscriber Information The following table defines the specific details associated with Loop 2320 Other Subscriber Information. Note: A hyphen in the table below means N A. Table 20. Loop 2320 Other Subscriber Information Page Loop ID Reference Name Codes Content Length Notes Comments 355 2320 SBR01 Payer Responsibility Sequence Number Code - 1 The SBR must contain a different value in each iteration of the SBR01. Each value may only be used one time per claim. 356 2320 SBR09 Claim Filing Indicator Code - 2 The value cannot be MA or MB. - 2320 CAS Claim Level Adjustment - - CAS segment must not be present when 2000B SBR01 P. 364 2320 AMT01 COB Payer Paid Amount D - Medicare requires that one occurrence of 2320 loop with an AMT segment where AMT01 D must be present when 2000B SBR01 S. 10.4.9 Loop 2330A Other Subscriber Name The following table defines the specific details associated with Loop 2330A Other Subscriber Name. Note: A hyphen in the table below means N A. Table 21. Loop 2330A Other Subscriber Name Page Loop ID Reference Name Codes Content Length Notes Comments 378 2330A NM105 Other Insured Middle Name - 25 The first position must be alphabetic (A-Z). CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 24 Page Loop ID Reference Name Codes Content Length Notes Comments 383 2330A REF02 Other Insured Additional Identifier - 9 Must be 9 digits with no punctuation. First 3 digits cannot be higher than 272. Digits 1-3, 4-5, and 6-9 cannot be zeros. 10.4.10 Loop 2330B Other Payer Name The following table defines the specific details associated with Loop 2330B Other Payer Name. Note: A hyphen in the table below means N A. Table 22. Loop 2330B Other Payer Name Page Loop ID Reference Name Codes Content Length Notes Comments 389 2330B DTP03 Adjudication or Payment Date - 35 Must not be future date. 10.4.11 Loop 2400 Service Line Number The following table defines the specific details associated with Loop 2400 Service Line Number. Note: A hyphen in the table below means N A. Table 23. Loop 2400 Service Line Number Page Loop ID Reference Name Codes Content Length Notes Comments 423 2400 LX01 Assigned Number - - LX01 must be greater than zero and less than or equal to 449. An individual claim with service lines greater than 449 will be rejected (However, the transmission of claims will be accepted, per HIPAA). 425 2400 SV202-1 Product or Service ID Qualifier HC, HP 2 Must be HC or HP. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 25 Page Loop ID Reference Name Codes Content Length Notes Comments 426 2400 SV202-2 Procedure Code - - If A0427, A0428 (with a QL modifier in SV202-3, SV202-4, SV202-5, or SV202-6), A0425, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0488, or A0436 (non- scheduled transportation claim) are the only codes present, 2310A NM1 must not be preset. Otherwise, 2310A NM1 must be present. 427 2400 SV203 Line Item Charge Amount - 10 SV203 must be greater than zero. SV203 s decimal positions are limited to 0, 1, or 2. 428 2400 SV205 Quantity - 15 SV205 must be greater than zero and less than or equal to 999,999.9. Must be 0 or 1 decimal position. 434 2400 DTP03 Service Date - 35 Must not be a future date, except for type of bill 0322 after 1 1 2021 10.4.12 Loop 2410 Drug Identification The following table defines the specific details associated with Loop 2410 Drug Identification. Note: A hyphen in the table below means N A. Table 24. Loop 2410 Drug Identification Page Loop ID Reference Name Codes Content Length Notes Comments 452 2410 CTP04 National Drug Unit Count - 15 CTP04 must be greater than 0 and less than or equal to 9,999,999.999. CTP04 is limited to up to 3 decimal positions. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 26 10.4.13 Loop 2420A Operating Physician Name The following table defines the specific details associated with Loop 2420A Operating Physician Name. Note: A hyphen in the table below means N A. Table 25. Loop 2420A Operating Physician Name Page Loop ID Reference Name Codes Content Length Notes Comments 457 2420A NM105 Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.14 Loop 2420B Other Operating Physician Name The following table defines the specific details associated with Loop 2420B Other Operating Physician Name. Note: A hyphen in the table below means N A. Table 26. Loop 2420B Other Operating Physician Name Page Loop ID Reference Name Codes Content Length Notes Comments 462 2420B NM105 Other Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.15 Loop 2420C Rendering Provider Name The following table defines the specific details associated with Loop 2420C Rendering Provider Name. Note: A hyphen in the table below means N A. Table 27. Loop 2420C Rendering Provider Name Page Loop ID Reference Name Codes Content Length Notes Comments 467 2420C NM105 Rendering Provider Name - 25 The first position must be alphabetic (A-Z). 10.4.16 Loop 2420D Referring Provider Name The following table defines the specific details associated with Loop 2420D Referring Provider Name. Note: A hyphen in the table below means N A. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 27 Table 28. Loop 2420D Referring Provider Name Page Loop ID Reference Name Codes Content Length Notes Comments 472 2420D NM105 Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.17 Loop 2430 Line Adjudication Information The following table defines the specific details associated with Loop 2430 Line Adjudication Information. Note: A hyphen in the table below means N A. Table 29. Loop 2430 Line Adjudication Information Page Loop ID Reference Name Codes Content Length Notes Comments 477 2430 SVD03 Product Service ID Qualifier HC, HP 2 Must be HC or HP. 479 2430 SVD05 Quantity - 15 Must be greater than zero. Must be less than or equal to 999,999.9. Must be 0 or 1 decimal position. 479 2430 SVD06 Bundled Line Number - 6 Must be an integer (no decimals). 486 2430 DTP03 Line Check Remit Date - 35 Must not be a future date. 10.4.18 Transaction Set Trailer The following table defines the specific details associated with Transaction Set Trailer. Note: A hyphen in the table below means N A. Table 30. Transaction Set Trailer Page Loop ID Reference Name Codes Content Length Notes Comments 496 - SE02 Transaction Set Control Number - 9 Must have the same value as ST02. Must be greater than zero. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 28 11 Appendices 11.1 Implementation Checklist In order to go live with CGS EDI, the following requirements must be met: EDI Enrollment Form must be submitted or on file. EDI Application Approved Vendor Software or approved Clearinghouse or Billing Service Approved Network Service Vendor Upon approval of the request to exchange files with CGS, a letter will be sent to the requestor. 11.2 Transmission Examples Figure 3. Example of the 837I Control Segments and Envelopes Please refer to the GPNet communications manual posted under Manuals and user guides (https: www.cgsmedicare.com parta edi index.html). 11.3 Frequently Asked Questions Frequently asked questions can be accessed at: Medicare FFS EDI Operations (https: www.cms.gov ElectronicBillingEDITrans ) CGS Frequently asked questions (https: www.cgsmedicare.com ). Click on the line of business, then the FAQ s can be located on the menu. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 29 11.4 Acronym Listing Table 31. Acronyms Listing and Definitions Acronym Definition 276 276 Claim Status Request transaction 277 277 Claim Status Response transaction 277CA 277 Claim Acknowledgement 835 835 Electronic Remittance Advice transaction 837P 837 Professional Claims transaction 999 Implementation Acknowledgment ASC Accredited Standards Committee CAQH CORE Council for Affordable Quality Healthcare Committee on Operating Rules for Information Exchange CEDI Common Electronic Data Interchange CG Companion Guide CMS Centers for Medicare Medicaid Services CMN Certificate of Medical Necessity DME Durable Medical Equipment EDI Electronic Data Interchange ERA Electronic Remittance Advice FFS Medicare Fee-For-Service FISMA Federal Information Security Management Act GS GE GS Functional Group Header GE Functional Group Trailer HCPCS Healthcare Common Procedure Coding System HIPAA Health Insurance Portability and Accountability Act of 1996 HTTP Hyper Text Transfer Protocol HTTPS Hyper Text Transfer Protocol Secure IOM Internet-only Manual ISA IEA ISA Interchange Control Header IEA Interchange Control Trailer MAC Medicare Administrative Contractor MBI Medicare Beneficiary Identifier CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 30 Acronym Definition MIME Multipurpose Internet Mail Extensions NCPDP National Council for Prescription Drug Programs NPI National Provider Identifier NSV Network Service Vendor PDAC Pricing, Data Analysis and Coding PECOS Provider Enrollment Chain and Ownership System PHI Protected Health Information PID Packet Identifier sFTP Secure File Transfer Protocol SOAP Simple Object Access Protocol ST SE ST Transaction Set Header SE Transaction Set Trailer TA1 Interchange Acknowledgment TR3 Technical Report Type 3 TRN Transaction Acknowledgment report (CEDI proprietary report) WSDL Web Services Description Language X12 A standards development organization that develops EDI standards and related documents for national and global markets. (See the | /kaggle/input/edi-db-835-837/837I_compguide.pdf | 815189f6dea52a5dd9b38b3bba0f5280 | 815189f6dea52a5dd9b38b3bba0f5280_0 |
- 6 Must be an integer (no decimals). 486 2430 DTP03 Line Check Remit Date - 35 Must not be a future date. 10.4.18 Transaction Set Trailer The following table defines the specific details associated with Transaction Set Trailer. Note: A hyphen in the table below means N A. Table 30. Transaction Set Trailer Page Loop ID Reference Name Codes Content Length Notes Comments 496 - SE02 Transaction Set Control Number - 9 Must have the same value as ST02. Must be greater than zero. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 28 11 Appendices 11.1 Implementation Checklist In order to go live with CGS EDI, the following requirements must be met: EDI Enrollment Form must be submitted or on file. EDI Application Approved Vendor Software or approved Clearinghouse or Billing Service Approved Network Service Vendor Upon approval of the request to exchange files with CGS, a letter will be sent to the requestor. 11.2 Transmission Examples Figure 3. Example of the 837I Control Segments and Envelopes Please refer to the GPNet communications manual posted under Manuals and user guides (https: www.cgsmedicare.com parta edi index.html). 11.3 Frequently Asked Questions Frequently asked questions can be accessed at: Medicare FFS EDI Operations (https: www.cms.gov ElectronicBillingEDITrans ) CGS Frequently asked questions (https: www.cgsmedicare.com ). Click on the line of business, then the FAQ s can be located on the menu. CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 29 11.4 Acronym Listing Table 31. Acronyms Listing and Definitions Acronym Definition 276 276 Claim Status Request transaction 277 277 Claim Status Response transaction 277CA 277 Claim Acknowledgement 835 835 Electronic Remittance Advice transaction 837P 837 Professional Claims transaction 999 Implementation Acknowledgment ASC Accredited Standards Committee CAQH CORE Council for Affordable Quality Healthcare Committee on Operating Rules for Information Exchange CEDI Common Electronic Data Interchange CG Companion Guide CMS Centers for Medicare Medicaid Services CMN Certificate of Medical Necessity DME Durable Medical Equipment EDI Electronic Data Interchange ERA Electronic Remittance Advice FFS Medicare Fee-For-Service FISMA Federal Information Security Management Act GS GE GS Functional Group Header GE Functional Group Trailer HCPCS Healthcare Common Procedure Coding System HIPAA Health Insurance Portability and Accountability Act of 1996 HTTP Hyper Text Transfer Protocol HTTPS Hyper Text Transfer Protocol Secure IOM Internet-only Manual ISA IEA ISA Interchange Control Header IEA Interchange Control Trailer MAC Medicare Administrative Contractor MBI Medicare Beneficiary Identifier CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 30 Acronym Definition MIME Multipurpose Internet Mail Extensions NCPDP National Council for Prescription Drug Programs NPI National Provider Identifier NSV Network Service Vendor PDAC Pricing, Data Analysis and Coding PECOS Provider Enrollment Chain and Ownership System PHI Protected Health Information PID Packet Identifier sFTP Secure File Transfer Protocol SOAP Simple Object Access Protocol ST SE ST Transaction Set Header SE Transaction Set Trailer TA1 Interchange Acknowledgment TR3 Technical Report Type 3 TRN Transaction Acknowledgment report (CEDI proprietary report) WSDL Web Services Description Language X12 A standards development organization that develops EDI standards and related documents for national and global markets. (See the official ASC X12 website.) X12N Insurance subcommittee of X12 CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. 31 11.5 Change Summary The following table details the version history of this CG. Table 32. Companion Guide Version History Version Date Section(s) Changed Change Summary 1.0 November 5, 2010 All Initial Draft 2.0 January 3, 2011 All 1st Publication Version 3.0 April 2011 6.0 2nd Publication Version 4.0 September 2015 All 3rd Publication Version 4.0 June 2016 All Updated CMS URLs 5.0 March 2017 2.2,4.1.3,4.3 4.4 Updated hyperlinks and connectivity information 5.1 November 2017 All Updated CGS and CMS URL 6.0 March 2019 All 4th Publication Version 6.1 June 2020 1.3 11.4 6.2 April 2021 10.3.10 2400 DTP03 Service Date Language updated. 7.0 July 2022 All 508 Compliance 8.0 June 2023 3.1, 10.2.1 and 10.4.6 10.2.1 and 10.4.2 Added instruction for 4 postal code when not provided by USPS. 3.1 Corrected spelling of Implementation | /kaggle/input/edi-db-835-837/837I_compguide.pdf | 815189f6dea52a5dd9b38b3bba0f5280 | 815189f6dea52a5dd9b38b3bba0f5280_1 |
Health Care Claim 837 Companion Guide Version 1.5 Refers to the following Technical Report Type 3 Guides: ASC X12N 837 Institutional (version 005010X223A2) ASC X12N 837 Professional (version 005010X222A1) ASC X12N 837 Dental (version 005010X224A2) Blue Cross Blue Shield of Massachusetts, February 2024 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 2 Preface This is a companion guide to the ASC X12N Implementation guides that were adopted under the Health Insurance Portability and Accountability Act (HIPAA). This guide details the data content needed to electronically exchange with Blue Cross Blue Shield of Massachusetts (Blue Cross). Transmissions based on this guide, used with the X12N Technical Report Type 3 guides, are compliant with both X12 syntax and those guides. This guide adheres to the ASC X12N Implementation Guides adopted under HIPAA. This guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Technical Report Type 3 guides. The content in this guide will be revised and republished when Blue Cross Blue Shield of Massachusetts makes improvements and or changes to any referenced product, process, or program. This documentation is the confidential and proprietary property of Blue Cross Blue Shield of Massachusetts. Any unauthorized use, reproduction, or transfer of the documentation is strictly prohibited. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 3 Table of Contents INTRODUCTION................................................................................................................................6 WHAT IS HIPAA?..............................................................................................................................6 PURPOSE OF THE ASC X12N IMPLEMENTATION GUIDE............................................................................6 PURPOSE OF THE BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE...............................8 HOW TO OBTAIN COPIES OF THESE GUIDES............................................................................................8 INTENDED AUDIENCE..........................................................................................................................8 NPI INFORMATION.............................................................................................................................8 ESTABLISHING A TRADING PARTNER AGREEMENT WITH BLUE CROSS.........................................................9 ESTABLISHING CONNECTIVITY WITH BLUE CROSS..................................................................... 10 CONTACTS..................................................................................................................................... 10 SETTING UP YOUR CONNECTION........................................................................................................ 10 CHECKLIST: BEFORE YOU CAN SUBMIT TRANSACTIONS.......................................................................... 10 NEHEN........................................................................................................................................ 11 PASSWORD RESET PROTOCOL........................................................................................................... 11 Server accounts........................................................................................................................ 12 For individual user IDs............................................................................................................... 12 SECURITY...................................................................................................................................... 12 MAINTENANCE................................................................................................................................ 13 TESTING......................................................................................................................................... 14 CLAIMS TESTING PROCESS OVERVIEW................................................................................................ 14 BLUE CROSS PROVIDER SUPPORT.............................................................................................. 15 BLUE CROSS CLAIM SUBMISSION GUIDELINES........................................................................... 16 AVAILABLE COMMUNICATION FOLDERS................................................................................................ 16 FILE NAME EXTENSION (.837)............................................................................................................ 16 THE USAGE INDICATOR (ISA15) MUST BE APPROPRIATE........................................................................ 16 PROFESSIONAL DENTAL AND INSTITUTIONAL....................................................................................... 17 SPECIAL CHARACTERS IN CLAIMS DATA............................................................................................... 17 DELIMITERS................................................................................................................................... 17 DUPLICATE FILE TRANSACTIONS........................................................................................................ 17 BLUE CROSS IDENTIFICATION NUMBER REQUIREMENTS........................................................... 18 REPORTING.................................................................................................................................... 19 REPORT OVERVIEW......................................................................................................................... 19 REPORT SAMPLES........................................................................................................................... 21 TA1 (interchange acknowledgment)............................................................................................ 21 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 4 999 (functional acknowledgement)............................................................................................. 21 277 (acknowledgement of receipt of claim submission)................................................................ 21 PDF (Submitter Batch Report).................................................................................................... 24 BLUE CROSS SPECIFIC CONDITIONAL DATA REQUIREMENTS................................................... 25 PROFESSIONAL CLAIMS (837P) DATA REQUIREMENTS........................................................................... 25 General.................................................................................................................................... 25 Control segments...................................................................................................................... 25 Detail data................................................................................................................................ 27 INSTITUTIONAL CLAIMS (837I) DATA REQUIREMENTS............................................................................. 41 General.................................................................................................................................... 41 Control segments...................................................................................................................... 41 Detail data................................................................................................................................ 43 DENTAL CLAIMS (837D) DATA REQUIREMENTS.................................................................................... 52 General.................................................................................................................................... 52 Control segments...................................................................................................................... 52 Detail data................................................................................................................................ 54 SPECIAL BILLING INSTRUCTIONS................................................................................................. 61 COVERAGE SECONDARY TO MEDICARE OR OTHER PAYERS.................................................................... 61 837 SUBSCRIBER CLAIMS VS. DEPENDENT CLAIMS UNIQUE IDENTIFICATION............................................... 64 837 ATYPICAL PROVIDERS................................................................................................................ 64 LOOP SEGMENT USED BY ATYPICAL PROVIDERS SEGMENT NAME............................................................. 64 FACILITY CODE REQUIREMENTS FOR 837P AND 837I CLAIMS FOR BLUE CROSS......................................... 64 GENERAL INFORMATION ON SPECIAL BILLING INSTRUCTIONS................................................................... 65 837I type of bill (TOB) convention............................................................................................... 65 837I, 837P 837D Provider taxonomy codes.............................................................................. 66 837I Special billing Instructions for vent beds or complex rehab stays........................................... 66 Ambulatory surgi-centers (ASC) observation services............................................................... 67 837P Community mental health centers (CMHC) use of procedure code modifiers........................ 67 837P billing instructions for radiology services (professional and technical components)................ 68 837P CAA Surprise Billing (Consolidate Appropriations Act) 2022 Federal Mandate...................... 70 FREQUENCY CODES 5, 7, AND 8 GUIDELINES.............................................................................. 71 FREQUENCY CODE 5 (LATE CHARGES) INSTITUTIONAL 837I CLAIMS......................................................... 71 FREQUENCY CODE 7 (RESUBMISSION)................................................................................................ 73 FREQUENCY CODE 8 (FULL VOID)....................................................................................................... 75 MASSACHUSETTS 837 CLAIMS FOR OUT-OF-STATE MEDICAID AGENCIES................................ 76 REMITTANCE DATE........................................................................................................................ 79 NON-SPECIFIC PROCEDURE CODES REQUIRE A NARRATIVE IN SERVICE DETAIL LOOP.......... 79 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 5 REVISION HISTORY........................................................................................................................ 80 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 6 Introduction What is HIPAA? The Health Insurance Portability and Accountability Act - Administration Simplification (HIPAA- AS) requires that Blue Cross Blue Shield of Massachusetts, Medicare, and all other health insurance payers in the United States, comply with the electronic data interchange standards for health care as established by the Secretary of Health and Human Services. The ASC X12N Implementation Guide 837 version 5010 and the Addenda (A1) for Health Care Claims have been established as the standard for claims transactions compliance. Purpose of the ASC X12N implementation guide The ASC X12N Implementation Guide version 5010, Addenda (A1) for Health Care Claims (837), Health Care Claim Acknowledgement (277CA), and Health Care Claim Payment Advice (835) have been established as the standard for claims transactions compliance. Although the ASC X12N Implementation Guide contains requirements for use of specific segments and data elements within the segments, the guide was written for use by all health benefit payers. There are separate transactions for Health Care Claims: Institutional (837I), Professional (837P), and Dental (837D). Loops Loop usage within ASC X12N transactions and their implementation guides can be confusing. Carefully read the loop requirements in terms of the context or location within the transaction. The usage designator of a loop s beginning segment indicates the usage of the loop. If a loop is used, the first segment (initial segments) of that loop is required even if it is marked situational. If Then The usage of the first segment in a loop is marked required The loop must occur at least once, unless it is nested in a loop that is not being used. A note on the required initial segment of a nested loop will indicate dependency on the higher level loop. The first segment is situational There will be a segment note addressing use of the loop. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 7 Any required segments in loops beginning with a situational segment occur only when the loop is used. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 8 Purpose of the Blue Cross Blue Shield of Massachusetts Companion Guide This document is the Blue Cross Blue Shield of Massachusetts specific Companion Guide to the ASC X12N Implementation Guide. The goals of the Blue Cross Companion Guide are to describe: 1. How to become an EDI Trading Partner with Blue Cross Blue Shield of Massachusetts 2. How to set up, test, and maintain a Trading Partner relationship with Blue Cross Blue Shield of Massachusetts 3. When conditional data elements and segments must be used with Blue Cross Blue Shield of Massachusetts transactions 4. Codes and data elements that are not applicable to Blue Cross Blue Shield of Massachusetts transactions This Companion Guide supplements but does not contradict any requirements in the ASC X12N version 5010 Implementation Guide or the Addenda. How to obtain copies of these guides The ASC X12N Implementation Guides adopted for use in HIPAA transactions are available for purchase at: wpc-edi.com HIPAA The Blue Cross Blue Shield of Massachusetts Companion Guide is available electronically on the Provider Central website at: bluecrossma.com provider Intended audience The intended audiences for this document are: An officer of the corporation The provider s billing office The technical area responsible for submitting electronic claims transactions to Blue Cross Blue Shield of Massachusetts NPI information The most up-to-date National Provider Identifier (NPI) billing instructions are available on the Provider Central website at bluecrossma.com provider. Log on and click on Office Resources 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 9 to find links to billing instructions by provider type. Establishing a trading partner agreement with Blue Cross You must set up a Trading Partner Agreement in order to take advantage of the transactions and communication services offered by Blue Cross Blue Shield of Massachusetts. To start, speak with our EDI specialists (see Contacts). We will send you our starter kit which includes: Form name: Distributed to: The Provider Trading Partner Agreement An Officer of the Corporation empowered to enter a contract on behalf of the Corporation. The Trading Partner Enrollment Form Your billing office and information technology area (they should collaborate to fill out the form). The Secure File Transfer Account Request Form Your information technology group and agents of your billing office. We require that two signed hard copies of the Provider Trading Partner Agreement be delivered to Blue Cross and Blue Shield of Massachusetts, Inc. and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. at: 25 Technology Drive Hingham, MA 02043 Mail Stop 03-02 Attention: Scott Howard Director, Provider Operations EDI Services You may email both the Trading Partner Enrollment Form and Secure File Transfer Account Request Form to EDISupport bcbsma.com. Please use Enrollment and Security Forms in the subject line of the email. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 10 Establishing connectivity with Blue Cross This section explains the process for establishing connectivity to transmit and receive electronic transactions with Blue Cross Blue Shield of Massachusetts. It is important to note the difference between using http and https when accessing the servers. Contacts Type of contact Area contact Telephone number Technical Blue Cross EDI Support Team EDISupport bcbsma.com 1-800-771-4097 option 2 Setting up your connection Providers will deliver and pick up files via Blue Cross s Tumbleweed Secure File Transfer server: Blue Cross Tumbleweed Secure File Transfer Server DNS Test staging.sftp.bluecrossma.com Production sftp.bluecrossma.com The types of file transmissions include: Submitting 837s Retrieving 277Cas, 999s, TA1 s, Submitter Reports and 835s Checklist: Before you can submit transactions You must: Contact the EDI Support team (EDISupport bcbsma.com) Complete and return the following authorization forms: 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 11 Provider Trading Partner Agreement Trading Partner Enrollment Form (which will include your submitter ID) Secure File Transfer Account Request Form listing: o Your server (please include your primary and secondary contacts) o Your primary system administrator contact o Your secondary system administrator contact o Each individual business user requiring access When Blue Cross has processed these forms, you will receive: Tumbleweed mailbox and supporting directory o Please note: Your organization s SFTP folder will be created using your submitter id; for example, e: company tradingpartners (submitter id). This folder path will be shared with your organization. Tumbleweed user ID to connect your server to your Tumbleweed mailbox Two individual user IDs for users listed in Section 4 of the Secure File Transfer Account Request Form. The two users will be able to manually view and access their organization s mailboxes If requested, additional individual user IDs for business area users NEHEN Providers using NEHEN should contact the NEHEN contractor (Trizetto NEHEN) directly at 1-800-556-2231. Password reset protocol The password for your Tumbleweed account will be system-generated. Passwords will need to be reset every 90 days for individual user accounts. For server accounts, the password has a one year expiration. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 12 Server accounts We email each registered user three notices that the password is about to expire ( registered users are determined from the names and email addresses on the security form): 1. Ten days before expiration 2. Five days before expiration 3. On the day of expiration Once one registered user has visited the site to reset password, we will email each registered user the new password. The user must update their server to use the new password. For individual user IDs The Tumbleweed application will display an error message ( login invalid ), indicating that the password has expired after 90 or 365 days. Users must contact the EDI Production Support team at EDISupport bcbsma.com to have the password reset. The manage your password function can be used to: Reset a password before the 90 or 365-day expiration Obtain a new password if a password has been forgotten Security Blue Cross Blue Shield of Massachusetts is dedicated to maintaining the confidentiality of personal health information (PHI) and safeguarding member information as if it were our own. Associates are required to protect member privacy by using reasonable measures during all phases of the information-handling process: from collection and storage, to disclosure and disposal. This policy applies to the PHI of all applicants and past or present members. Information may be in the form of data in storage or in transit, on paper or in electronic format. Due to its sensitivity, the use and disclosure of PHI is restricted, except in circumstances where permitted or required by law or where appropriately authorized. Access to PHI is limited to those with a business need to know the information for treatment, payment, or health care operations, or as otherwise permitted or required by law. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 13 Maintenance Blue Cross allows transmission of 837 claim files 24 hours a day, seven days a week. For unscheduled maintenance (system abnormalities, outages), users will be notified via the contact information supplied on the Secure FTP Account Request Form. To avoid possible claim errors, please do not submit any files to Blue Cross during these periods. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 14 Testing Prior to submission to the product environment, Blue Cross requires testing for all sites submitting HIPAA claim submissions for the first time, as well as any claims processing changes related to Blue Cross Specific Data Elements. To help you achieve a successful test, please follow the appropriate format specifications (listed in this guide) and submission directions. To receive approval to move from test to production, you must receive a minimum correct rate of 95 for the test file submitted. Testing is an iterative process; Blue Cross will accept only one submission for each iteration of testing. Claims testing process overview Testing consists of the following stages: 1. File submission Coordinate with a Blue Cross EDI Support representative (see the Contacts section of this guide). For testing, we are not able to process a normal day of your production. However, the claims in your test file should simulate claims from normal business. Submit your test file to Blue Cross s Tumbleweed Secure File Transfer test server. A Blue Cross EDI Support analyst reviews the file for HIPAA compliance and Blue Cross segment requirements. 2. Test results A Blue Cross EDI Support analyst will contact you by phone with results of your most recent test. Additionally, you must retrieve your reports from the test Blue Cross Tumbleweed Secure File Transfer server. Note: Stages 1 and 2 will repeat until you achieve a minimum 95 correct rate for the most recent file submitted. 3. Approval When your latest test iteration has achieved the correct rate, production move approval will be sent to the primary contact email address listed on your Trading Partner Enrollment Form. You may then submit and retrieve your files from the production Tumbleweed Secure File Transfer server. Testing support is available Monday through Friday, 8:30 a.m. to 3:30 p.m. ET. Refer to the Contacts section for help. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 15 Blue Cross provider support If you cannot find the answers to your questions in this guide, please use the contact information below to reach the appropriate support area in Blue Cross. 1. Blue Cross EDI support For technical questions or help related to any transactions, acknowledgments, or reports related to your health care claim submissions, please contact Blue Cross EDI Support. Phone: 1-800-771-4097 (option 2) Email: EDISupport bcbsma.com 2. Provider Central website Provider Central provides information on our products, policies, and procedures, as well as FAQs and companion guides for various electronic transactions. Please refer to online documentation for the most current materials. Website: bluecrossma.com provider 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 16 Blue Cross claim submission guidelines Claim files submitted for testing production must meet the guidelines listed below. Available communication folders For each submitter ID that you can access, your security will allow you permission to two folders: inbound and outbound. Use the inbound folder to submit your ANSI 837 claim files and the outbound folder to retrieve the ANSI acknowledgement files and submitter report for each submitted ANSI 837 file. File name extension (.837) Claim files submitted to the inbound folder must have an extension of.837. You may continue to use your conventions and multiple nodes for the file name, but we can only process files from the inbound folder if its extension is.837. The usage indicator (ISA15) must be appropriate The usage indicator in the Interchange Control Header (ISA15) must be appropriate for the claim submission environment. Submissions for Must have ISA15 as Testing T Production P The result of an inappropriate usage indicator is reported only in an ANSI TA1 report. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 17 Professional Dental and Institutional Test claim files Should contain a minimum of 25 claims and not exceed 50 claims in any one transaction set (batch). For testing, we are not able to process a normal day of your production. However, the claims in your test file should simulate claims associated with your normal business. Production claim files Must not exceed 4,999 claims in any one transmission. You may send multiple transmissions per day but each must not exceed 4,999 claims. Special characters in claims data Avoid the use of special characters in the claim data itself. Punctuation comma (,), period (.), colon (:), semicolon (;), and hyphen (-) should be avoided in the claims data (e.g. names, addresses, identifiers). Delimiters Delimiters are characters used to separate data and component elements or to terminate a segment. The following delimiters should be used when submitting an 837 claim file: Character Name Asterisk data element separator Carat repetition separator: Colon component element separator Tilde segment terminator Duplicate file transactions Blue Cross will not process an 837 transaction submitted with duplicate ISA13 control numbers. Please submit all transactions with unique ISA13 control numbers that have not been submitted to Blue Cross in previous transactions. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 18 Blue Cross identification number requirements Alpha Numeric alphanumeric Massachusetts Blue Cross Three letter alpha prefix Nine (without prefix) numeric or twelve (with prefix) alphanumeric characters Out-of-state Blue Cross Three letter alpha prefix Alphanumeric characters (typically 12-14) Federal Employee Plan (FEP) The letter R Eight numeric characters Note: Member IDs should not contain hyphens, spaces, or any special characters. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 19 Reporting This section describes the reports that are available to you from Blue Cross. The reports are stored for up to fourteen days for retrieval. Report overview Blue Cross generates the following list of reports. The quick reference table is followed by a description and sample of each report. For questions about any of the reports, use the Contacts section of this guide. Report name About the report TA1 BCBSMA. submitter ID. InterchangeAck. datetime.TA1 The TA1 or Interchange Acknowledgment is a reply to an interchange or transmission that has been sent. The TA1 verifies the envelopes only. This report notifies you of problems that were encountered in the interchange control structure. It acknowledges that we have received or rejected an entire transmission. 999 BCBSMA. submitter ID. FunctionalAck. datetime.999 The 999 or Functional Acknowledgment is a reply to the functional groups that are in any one interchange or transmission. It notifies you of our ability or inability to process the entire transaction based on ASC X12 syntax and structure rules. 277CA BCBSMA. submitter ID. ClaimAck. datetime.277 Our front-end includes Business and HIPAA rules to pre- process your claims. We send the 277 (often referred to as the Unsolicited 277) to notify you of transactions that are accepted for adjudication, as well as those that are not accepted. Claims failing our front-end editing process are not forwarded to the claims adjudication system. Claims passing the front-end editing process are forwarded to the claims adjudication system. PDF BCBSMA. submitter ID. In addition to the ANSI transactions available to you, we prepare a user-friendly Submitter Batch Report in Adobe PDF format. There are two sections a summary 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 20 SubmitterReport. datetime.PDF and a detail. Totals are presented in the summary for each transmission. Information about each claim is available in the detail section. 835 BCBSMA. Submitter ID. ClaimPayment. datetime.835 If you have elected to receive your remittance advices electronically, this transaction will be sent to your mailbox once claims have been adjudicated. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 21 Report samples Below are samples of each of the claim submission reports. The generic name in parentheses appears after the report name. The report samples are random samples from different batches of claims. TA1 (interchange acknowledgment) The TA1 report acknowledges that we have received or rejected an entire transmission. The report is delivered to your mailbox in stream format. For illustration purposes only, the report has been reformatted to show the individual segments. ISA 00 00 ZZ 00200 ZZ SUBMITTER ID 080630 1550 U 00501 000000069 0 T TA1 000197660 080630 0951 A 000 IEA 0 000000069 999 (functional acknowledgement) The 999 indicates accepted and rejected transaction sets within an interchange. For illustration purposes only, the report has been reformatted to show the individual segments. ISA 00 00 ZZ 00200 ZZ SUBMITTER ID 080630 1551 U 00501 000000070 0 T GS FA 00200 SUBMITTERID 20080630 1551 35 X 005010X223 ST 999 0001 AK1 HC 197665 AK2 837 000000001 AK5 A AK9 A 1 1 1 SE 8 0001 GE 1 35 IEA 1 000000070 277 (acknowledgement of receipt of claim submission) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 22 The 277 notifies you of transactions that have passed our front-end edits and will be forwarded to the adjudication system. Also included are transactions that have failed the front- end and will not be forwarded for adjudication. The report is delivered to your mailbox in stream format. For illustration purposes only, the report has been reformatted to show the individual segments. ISA 00 00 ZZ 00200 ZZ SUBMITTER ID 080630 1551 00501 000000035 0 T GS HN 00200 CU01 20080630 1551 35 X 005010X214 ST 277 0001 005010X214 BHT 0085 08 39403.1 20080630 155036 TH HL 1 20 1 NM1 PR 2 MA BLUE SHIELD 46 00200 TRN 1 39403 DTP 050 D8 20080630 DTP 009 D8 20080630 HL 2 1 21 1 NM1 41 2 SUBMITTER NAME 46 SUBMITTERID TRN 2 155E37 STC A1 19 65 20080630 WQ 793 QTY 90 4 QTY AA 2 AMT YU 578 AMT YY 215 HL 3 2 19 1 NM1 85 2 PROVIDER NAME XX NPI TRN 1 2 REF EI 042888373 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 23 QTY QA 1 QTY QC 2 AMT YU 207 AMT YY 215 HL 4 3 PT NM1 QC 1 LASTNAME FIRSTNAME MI SUBSCRIBERID TRN 2 6608108431353 STC A1 19 65 20080630 WQ 207 REF D9 23081081511500 HL 5 4 PT NM1 QC 1 LASTNAME FIRSTNAME MI SUBSCRIBERID TRN 2 6608112681460 STC A7 486 65 20080630 U 81 H51000 The Procedure Code 'ADMIN' is not a valid CPT or HCPCS Code for this Date of Service. REF D9 43081124916400 HL 6 4 PT NM1 QC 1 LASTNAME FIRSTNAME MI SUBSCRIBERID TRN 2 6608108431346 STC A7 400 65 20080630 U 134 H30011 The Sum of the SV1-02 elements is not equal to CLM-02 in the 2300 loop. REF D9 43081081694500 SE 39 0001 GE 1 35 IEA 1 000000035 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 24 PDF (Submitter Batch Report) The PDF Submitter Batch Report is not a technical ANSI transaction. It is delivered to your mailbox as a PDF so that you may have a visual report. The first section is a summary report for the transmission. The second section provides details for each claim for each provider. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 25 Blue Cross specific conditional data requirements Professional claims (837P) data requirements General This section will clarify when conditional data elements and segments must be used for Blue Cross professional claim transactions and will help you complete the 837P transaction. If you follow these guidelines, we'll be able to process your claims more accurately and efficiently. Control segments 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions ISA - INTERCHANGE CONTROL HEADER ISA Interchange control header To start and identify an interchange of zero or more functional groups and interchange-related control segments ISA01 I01 Authorizatio n information qualifier Required Use: 00 (no authorization information present no meaningful information in I02) ISA02 I02 Authorizatio n information Required Use: 10 spaces ISA03 I03 Security information qualifier Required Use: 00 (no security information present no meaningful 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 26 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions information in I04) ISA04 I04 Security information Required Use: 10 spaces ISA05 I05 Interchange ID qualifier Required, qualifies the sender in ISA06 Use: ZZ (mutually defined) ISA06 I06 Interchange sender ID Required Use: Your submitter ID (the same code used in GS02 and loop 1000A NM109) ISA07 I07 Interchange ID Qualifier Required, qualifies the receiver in ISA08 Use: ZZ (mutually defined) ISA08 I08 Interchange Receiver ID Required Use: 00200 (BCBSMA) GS - FUNCTIONAL GROUP HEADER GS Functional Group Header To indicate the beginning of a functional group and to provide control information 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 27 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions GS02 142 Application Sender Code Required Use: Your submitter ID (the same code used in ISA06 and loop 1000A NM109) GS03 124 Application Receiver Code Required Use: 00200 (BCBSMA) GS08 480 Version Release Industry ID Code Required Use: 005010X222A1 (Professional Implementation Guide plus Addenda) Detail data 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 1000A Submitter Name 020 NM1 Submitter name To supply the full name of an individual or organizational entity 020 NM109 67 Identification code Required Use your submitter ID (the same code used in ISA06 and GS02) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 28 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 1000B Receiver Name 020 NM1 Receiver name To supply the full name of an individual or organizational entity 020 NM109 67 Identification code Required Use: 00200 (BCBSMA) Loop 2000A Billing Pay to Provider Hierarchical Level 003 PRV Billing pay- to provider specialty information To specify the identifying characteristics of a provider 003 PRV02 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use: ZZ (health care provider taxonomy code list) 003 PRV03 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 29 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 2010AA Billing Provider Name 015 NM1 Billing provider name To supply the NPI 015 NM108 66 Identification code qualifier Required Use: XX (NPI) 015 NM109 67 Identification code Required Use: The billing provider s 10-digit NPI Loop 2010AA Billing Provider Secondary Identification 035 REF Reference identification To identify the tax ID (1099 number) of the billing provider 035 REF01 128 Reference identification qualifier Required, used to provide the tax ID number of the billing provider Use: EI (EIN number) OR SY (SSN number) 035 REF02 127 Reference identification Required, used to provide the tax ID number of the billing provider Use the billing provider s 9-digit tax ID number (without dashes) Loop 2000B Subscriber Information 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 30 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions 005 SBR Subscriber information To record information specific to the primary insured and the insurance carrier for that insured 005 SBR02 1069 Individual relationship code Situational, but required if the subscriber is the patient Use: 18 (self) if the subscriber is the patient Important Note: Use this code only when the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, do not use this element. Loop 2010BA Subscriber Name 015 NM1 Individual or organizationa l name To supply the full name of an individual or organizational entity 015 NM109 67 Identification code Situational, but required if the subscriber is the patient Use the patient s identification number that was in effect on the date of service, exactly as it appears on the BCBS ID card. You must include the appropriate alpha prefix. Note: We do not issue unique identification numbers to all individual 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 31 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions members. When submitting claims for a dependent, submit the 2010CA loop and the dependent s demographic segments, along with the data for the actual subscriber of the policy in loop 2010BA. Loop 2010BB Payer Name 015 NM1 Individual or organization name Information about the Payer 015 NM108 Identification code qualifier Required Use: PI (Payer) 015 NM109 Identification code Required Use: 00200 (BCBSMA) Loop 2300 Claim Information 130 CLM Health claim Use to identify an early intervention provider 130 CLM12 1366 Special program code Situational, but required if you have been instructed by Blue Cross to include the special program indicator to identify yourself as a contracted early Use: 01 if the service relates to early periodic screening, diagnosis and treatment (EPSDT) or child health assessment program (CHAP) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 32 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions intervention provider Refer to Appendix C 837P Special Program Indicator Loop 2300 Date of Accident 135 DTP Date, time, or period To specify any or all of a date, a time, or a time period related to an accident 135 DTP01 374 Date time qualifier Situational, but required if CLM11-1, CLM11-2, or CLM11-3 AA (auto accident), AP (another party responsible), EM (employment) or OA (other accident) Use: 439 if the service involves an accident 135 DTP02 1250 Reference identification Situational, but required if CLM11-1, CLM11-2, or CLM11-3 AA (auto accident), AP (another party responsible), EM (employment) or OA (other accident) Use: D8 (date expressed in format CCYYMMDD OR DT (date and time expressed in format CCYYMMDDHHMM) 135 DTP03 1251 Date time period Situational, but required if CLM11-1, If you have indicated an injury diagnosis code, the date of the 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 33 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions CLM11-2, or CLM11-3 AA (auto accident), AP (another party responsible), EM (employment) or OA (other accident) injury or accident is required Loop 2310B Rendering Provider Name 250 NM1 Rendering provider name To supply the NPI 250 NM108 66 Identification code qualifier Required Use: XX (NPI) 250 NM109 67 Identification code Required, used to provide the NPI of the rendering provider Use the rendering provider s 10- digit NPI 255 PRV02 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use: ZZ (health care provider taxonomy code list) 255 PRV03 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 34 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions code taxonomy code in order to crosswalk your NPI, it is required. Refer to Appendix C837I 837P Provider Taxonomy Codes Loop 2310D Service Facility Location 250 NM1 Service facility location Use to identify the facility where the services were rendered 250 NM101 98 Entity identifier code Situational, but required when the location of the health care service is different than that carried in the 2010AA (billing provider) or 2010AB (pay-to provider) loops. If the NPI is not different than the NPI submitted in 2010AA do not send the NPI in this loop. Use: One of the following values: 77 (service location use when other codes in this element do not apply) FA (facility) Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 250 NM102 1065 Reference identification Situational, but required when the Use: 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 35 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions qualifier location of the health care service is different than that carried in the 2010AA (billing provider) or 2010AB (pay-to provider) loops 2 (non-person entity) Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 250 NM103 1035 Reference identification qualifier Situational, but required when the location of the health care service is different than that carried in the 2010AA (billing provider) or 2010AB (pay-to provider) loops Use: The name of the service facility where the services were rendered Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 250 NM108 66 Reference identification qualifier Situational, but required when the location of the health care service is different than that carried in the 2010AA (billing Provider) or 2010AB (pay-to provider) loops Required, if NPI is known Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 36 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions 250 NM109 67 Reference identification Situational, but required when the location of the health care service is different than that carried in the 2010AA (billing provider) or 2010AB (pay-to provider) loops Required, if NPI is known Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 265 N3 Service facility location address Use to identify the address of the facility where the services were rendered 265 N301 166 Address information Required when reporting a service facility location in NM1 Use: Address line 1 of the service facility location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 265 N302 166 Address information Required when reporting a service facility location in NM1 Use: Address line 2 of the service facility location 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 37 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 270 N4 Service facility location city state ZIP Use to identify the city, state, and ZIP Code of the facility where the services were rendered 270 N401 19 Address information Required when reporting a service facility location in NM1 Use: City of the service facility location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 270 N402 156 Address information Required when reporting a service facility location in NM1 Use: State of the service facility location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 270 N403 116 Address information Required when reporting a service Use: ZIP code of the service facility 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 38 Loop 2400 Professional Service 370 SV1 Professional service To specify the claim service detail for a Health Care professional 370 SV101- 1 235 Product service ID qualifier Required, code identifying the type source of the Use the appropriate HCPCS J- code (HC) for applicable drugs or injections. If the J-code is a 837P implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions facility location in NM1 location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 271 REF Service facility location secondary identification Use if a secondary number is necessary to identify the facility where the services were rendered 271 REF01 128 Reference identification qualifier Not required Not required 271 REF02 127 Reference identification Not required Not required 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 39 Loop 2400 Professional Service 370 SV1 Professional service To specify the claim service detail for a Health Care professional descriptive number used in product service ID generic code requiring further explanation, also report the national drug code (NDC) in the LIN segment of loop 2410. 370 SV101- 3 1339 Procedure modifier Required when a modifier clarifies improves the reporting accuracy of the associated procedure code Blue Cross requires standard modifiers for technical components (TC), professional components (26), and community mental health centers (AF, AH, AJ, HA, HE, HH, HI, HO, HR, TD). In addition, use standard modifiers when other services require them. Refer to the CPT and HCPCS manuals for a complete listing of standard modifiers. Refer to Appendix C. 837P Community Mental Health Centers Use of Procedure Code Modifiers Loop 2410 Drug Identification 494 LIN Item identification The NDC number used to specify billing reporting for drugs provided that may be part of the service(s) described in SV1 494 LIN02 235 Product service ID qualifier Situational, but required if this loop Use N4 (national drug code in 5- 4-2 Format) if the J-code reported 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 40 Loop 2400 Professional Service 370 SV1 Professional service To specify the claim service detail for a Health Care professional is used in SV1 is a generic code that requires further explanation. 494 LIN03 234 Product service ID Situational, but required if the qualifier N4 is used Use: The NDC number in 5-4-2 format Loop 2420A Rendering Provider Name 500 NM1 Individual or organizational name To supply the full name of an individual or organizational entity 500 NM108 66 Identification code qualifier Required if the rendering provider is different from the provider identified in 2310A Use: XX (NPI) 500 NM109 67 Identification code Required if the rendering provider is different from the provider identified in 2310A Use the rendering provider s 10- digit NPI Back to top 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 41 Institutional Claims (837I) data requirements General The purpose of this section is to clarify when conditional data elements and segments must be used for Blue Cross institutional claims transactions. The following information is designed to help you complete the 837I transaction. If you follow these guidelines, we'll be able to process your claims more accurately and efficiently. Control segments 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross Blue Shield of MA instructions ISA Interchange Control Header ISA Interchange control header To start and identify an interchange of zero or more functional groups and interchange-related control segments ISA01 I01 Authorization information qualifier Required Use: 00 (no authorization information present no meaningful information in I02) ISA02 I02 Authorization information Required Use: 10 Spaces ISA03 I03 Security information qualifier Required Use: 00 (no security information present no meaningful information in I04) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 42 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross Blue Shield of MA instructions ISA04 I04 Security information Required Use: 10 Spaces ISA05 I05 Interchange ID qualifier Required, qualifies the sender in ISA06 Use: ZZ (mutually defined). ISA06 I06 Interchange sender ID Required Use: Your submitter ID (the same code used in GS02 and loop 1000A NM109) ISA07 I07 Interchange ID qualifier Required, qualifies the receiver in ISA08 Use: ZZ (mutually defined) ISA08 I08 Interchange receiver ID Required Use: 00200 (Blue Cross) GS Functional Group Header GS Functional group header To indicate the beginning of a functional group and to provide control information GS02 142 Application sender code Required Use: Your submitter ID (the same code used in ISA06 and loop 1000A NM109) GS03 Application receiver Required Use: 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 43 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross Blue Shield of MA instructions 124 code 00200 (Blue Cross) GS08 480 Version release industry identifier code Required Use: 005010X223A2 (Institutional Implementation Guide plus Addenda) Detail data 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 1000A Submitter Name 020 NM1 Submitter name To supply the full name of an individual or organizational entity 020 NM109 67 Identification code Required Use your submitter ID (the same code used in ISA06 and GS02) Loop 1000B Receiver Name 020 NM1 Receiver To supply the full name of an individual or organizational 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 44 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions name entity 020 NM109 67 Identification code Required Use: 00200 (BCBSMA) Loop 2000A Billing Pay-to-Provider Specialty Information 003 PRV Provider information To specify the identifying characteristics of a provider 003 PRV02 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use: ZZ (health care provider taxonomy code list) 003 PRV03 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. Refer to Appendix C 837I 837P Provider Taxonomy Codes Loop 2010AA Billing Provider Name 015 NM1 Individual or To specify the primary To supply the NPI 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 45 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions organizational name identification of the billing provider. 015 NM108 66 Identification code qualifier Required Use: XX (NPI) 015 NM109 67 Identification code Required Use: The billing provider s 10- digit NPI Loop 2010AA Billing Provider Secondary ID 035 REF Reference identification Use if a secondary number is necessary to identify the billing provider 035 REF01 128 Reference identification qualifier Required, used to provide the tax ID number of the billing provider Use: EI (EIN number) or SY (SSN number) 035 REF02 127 Reference identification Required, used to provide the tax ID number of the billing provider Use: The billing provider s 9- digit tax ID number (without dashes) Loop 2000B Subscriber Information 005 SBR Subscriber information To record information specific to the primary insured and the insurance carrier for that insured 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 46 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions 005 SBR02 1069 Individual relationship Code Situational, but required if the subscriber is the patient Use: 18 (self) if the subscriber is the patient Important Note: Use this code only when the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, do not use this element. Loop 2010BA Subscriber Name 015 NM1 Individual or organization name To supply the full name of an individual or organizational entity 015 NM109 67 Identification code Situational, but required if the subscriber is the patient Use the patient s identification number that was in effect on the date of service, exactly as it appears on the Blue Cross ID card. You must include the appropriate alpha prefix. Note: We do not issue unique identification numbers to all individual members. When submitting claims for a dependent, submit the 2010CA 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 47 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions loop and the dependent s demographic segments, along with the data for the actual subscriber of the policy in loop 2010BA. DETAIL DATA 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer 015 NM108 Identification code qualifier Required Use: PI (payer identification) 015 NM109 Identification code Required Use: 00200 (BCBSMA) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 48 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer Loop 2300 Claim Information 130 CLM Health claim To specify basic data about the claim 130 CLM05-1 1331 Facility code value Required Required. For acute care hospitals, Blue Cross will crosswalk your NPI using this field as a secondary qualifier to your NPI. Loop 2310A Attending Physician Name 250 NM1 Individual or organizational name Use if it is necessary to identify the attending provider 250 NM108 66 Identification code qualifier Required, if loop is submitted Use: XX (NPI) 250 NM109 67 Identification code Required, if loop is submitted Use: The attending physician s 10- 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 49 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer digit NPI Loop 2310A Attending Physician Name 255 PRV Provider information To specify the identifying characteristics of an attending provider 003 PRV02 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use the code ZZ to indicate the health care provider taxonomy code list. 003 PRV03 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. Refer to Appendix C 837I 837P Provider Taxonomy Codes 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 50 Detail data 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 | /kaggle/input/edi-db-835-837/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_0 |
required if the subscriber is the patient Use the patient s identification number that was in effect on the date of service, exactly as it appears on the Blue Cross ID card. You must include the appropriate alpha prefix. Note: We do not issue unique identification numbers to all individual members. When submitting claims for a dependent, submit the 2010CA 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 47 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions loop and the dependent s demographic segments, along with the data for the actual subscriber of the policy in loop 2010BA. DETAIL DATA 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer 015 NM108 Identification code qualifier Required Use: PI (payer identification) 015 NM109 Identification code Required Use: 00200 (BCBSMA) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 48 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer Loop 2300 Claim Information 130 CLM Health claim To specify basic data about the claim 130 CLM05-1 1331 Facility code value Required Required. For acute care hospitals, Blue Cross will crosswalk your NPI using this field as a secondary qualifier to your NPI. Loop 2310A Attending Physician Name 250 NM1 Individual or organizational name Use if it is necessary to identify the attending provider 250 NM108 66 Identification code qualifier Required, if loop is submitted Use: XX (NPI) 250 NM109 67 Identification code Required, if loop is submitted Use: The attending physician s 10- 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 49 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer digit NPI Loop 2310A Attending Physician Name 255 PRV Provider information To specify the identifying characteristics of an attending provider 003 PRV02 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use the code ZZ to indicate the health care provider taxonomy code list. 003 PRV03 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. Refer to Appendix C 837I 837P Provider Taxonomy Codes 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 50 Detail data 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 2310B Operating Physician Secondary ID 271 REF Reference identification Use if a secondary number is necessary to identify the operating physician provider 271 REF01 128 Reference identification qualifier Not required Not required Loop 2310C Other Provider Secondary ID 271 REF Reference identification Use if a secondary number is necessary to identify the other provider 271 REF01 128 Reference identification qualifier Not required Not required Loop 2400 Institutional Service Line 375 SV2 INSTITUTIONAL SERVICE LINE To specify the claim service detail for a Health Care institution 375 SV201 234 Product service ID Required Required. Blue Cross has issued special billing instructions when billing for vent beds or complex rehabilitation stays. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 51 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions See Appendix C 837I Special Billing Instructions for Revenue Codes 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 52 Dental Claims (837D) Data Requirements General The purpose of this section is to clarify when conditional data elements and segments must be used for Blue Cross Blue Shield of Massachusetts dental claims transactions. The following information is designed to help you complete the 837D transaction. If you follow these guidelines, we'll be able to process your claims more accurately and efficiently. Control segments 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions ISA Interchange Control Header ISA Interchange control header To start and identify an interchange of zero or more functional groups and interchange-related control segments ISA01 I01 Authorization information qualifier Required Use: 00 (no authorization information present no meaningful information in I02) ISA02 I02 Authorization information Required Enter: 10 spaces ISA03 I03 Security information qualifier Required Use: 00 (no security information present no meaningful 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 53 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions information in I04) ISA04 I04 Security information Required Enter: 10 spaces ISA05 I05 Interchange ID qualifier Required, this ID qualifies the Sender in ISA06 Use: ZZ (mutually defined) ISA06 I06 Interchange sender ID Required Use: Your submitter ID (the same code used in GS02 and loop 1000A NM109) ISA07 I07 Interchange ID qualifier Required. This ID qualifies the receiver in ISA08 Use: ZZ (mutually defined) ISA08 I08 Interchange receiver ID Required Use: 00200 (BCBSMA) GS Functional Group Header GS Functional group header To indicate the beginning of a functional group and to provide control information GS02 142 Application sender Required Use: Your submitter ID (the same 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 54 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions code code as used in ISA06 and Loop 1000A NM109) GS03 124 Application receiver code Required Use: 00200 (BCBSMA) GS08 480 Version release industry identifier code Required Use: 005010X224A2 (Dental Implementation Guide plus Addenda) Detail data 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross instructions Loop 1000A Submitter Name 020 NM1 Submitter name To supply the full name of an individual or organizational entity 020 NM109 67 Identification code Required Use: Your submitter ID (the same code as used in ISA06 and 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 55 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross instructions GS02) Loop 1000B Receiver Name 020 NM1 Receiver name To supply the full name of an individual or organizational entity 020 NM109 67 Identification code Required Use: 00200 (BCBSMA) Loop 2000A Billing Pay-to-Provider Specialty Information 003 PRV Provider information To specify the identifying characteristics of a provider 003 PRV02 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use: The code ZZ to indicate the health care provider taxonomy code list. 003 PRV03 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 56 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross instructions Loop 2010AA Billing Provider Name 015 NM1 Individual or organizational name To supply the NPI 015 NM108 66 Identification code qualifier Required Use: XX (NPI) 015 NM109 67 Identification code Required Use: The billing provider s 10-digit NPI Loop 2010AA Billing Provider Secondary Identification 035 REF Reference Identification Use to identify the Tax ID (1099 number) of the billing provider 035 REF01 128 Reference identification qualifier Required, used to provide the tax ID number of the billing provider Use: EI (EIN Number) OR SY (SSN number) 035 REF02 127 Reference identification Required, used to submit the tax ID number of the billing provider Use: The billing provider s 9-digit tax ID number (without dashes) Loop 2000B Subscriber Information 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 57 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross instructions 005 SBR Subscriber information To record information specific to the primary insured and the insurance carrier for that insured 005 SBR02 1069 Individual relationship code Situational, but required if the subscriber is the patient Use: 18 (Self) if the subscriber is the patient Important note: If the subscriber is not the patient, do not use this data element. Refer to the appropriate patient segments. Loop 2010BA Subscriber Name 015 NM1 Individual or organizational name To supply the full name of an individual or organizational entity 015 NM109 67 Identification code qualifier Situational, but required if the subscriber is the patient Use the patient s identification number that was in effect on the date of service, exactly as it appears on the BCBS ID card. You must include the appropriate alpha prefix. Note: We do not issue unique identification numbers to all individual members. When submitting claims for a 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 58 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross instructions dependent, submit the 2010CA loop and the dependent s demographic segments, along with the data for the actual subscriber of the policy in loop 2010BA. Loop 2010BB Payer Name 015 NM1 Individual or organizational name Information about the payer 015 NM108 Identification code qualifier Required Use: PI (payer identification) 015 NM109 Identification code Required Use: 00200 (BCBSMA) Loop 2300 Date of Accident 135 DTP Date or time or period To specify the date of an accident 135 DTP01 374 Date time qualifier Situational, but required if CLM11-1, CLM11-2, or CLM11-3 AA (auto accident), EM (employment) or OA (other accident) Use: 439 if the service involves an accident 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 59 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross instructions 135 DTP02 1250 Reference identification Situational, but required if CLM11-1, CLM11-2, or CLM11-3 AA (auto accident), EM (employment) or OA (other accident) Use: D8 (date expressed in format CCYYMMDD 135 DTP03 - 1251 Date time period Situational, but required if CLM11-1, CLM11-2, or CLM11-3 AA (auto accident), EM (employment) or OA (other accident) If you have indicated a diagnosis code value greater than 80000 (injury), the date of the injury or accident is required. Loop 2300 Claim Note 190 NTE Note special instruction To transmit information in a free-format, if necessary, for comment or special instruction 190 NTE01 363 Note reference code Situational, but required for reporting periodontal charting information Use: ADD (Additional Information) Blue Cross requires this segment for periodontal services in order to report the periodontal case type 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 60 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross instructions 190 NTE02 352 Description Situational, but required for reporting periodontal charting information Required when billing for the following periodontal procedures: D4341 and D4910 Use the following values to report periodontal case types: PERI1: Case type I - gingival disease PERI2: Case type II - early periodontitis PERI3: Case type III - moderate periodontitis PERI4: Case type IV - advanced periodontitis Loop 2310B Rendering Provider Name 250 NM1 Rendering provider name To supply the NPI 250 NM108 66 Identification code qualifier Required Use: XX (NPI) 250 NM109 67 Identification code Required, used to provide the NPI of the rendering treating provider Use the rendering provider s 10- digit NPI 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 61 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross instructions 255 PRV02 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use: ZZ (health care provider taxonomy code list) 255 PRV03 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. Refer to Appendix C 837I 837P Provider Taxonomy Codes Special BILLING Instructions Coverage secondary to Medicare or other payers If the 837 claim transaction reports that Blue Cross Blue Cross Blue Shield Massachusetts is the secondary payer to Medicare or another payer (Coordination of Benefits information), review the following to ensure the data is populated correctly. Refer to the appropriate 837 Technical Type 3 Report Guide for further clarification. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 62 Blue Cross realizes that the depth of Coordination of Benefits information returned to you in the Primary Payer s remittance may be less than ideal, but we ask you to work with these payers so that we may properly adjudicate your claim. The following information is required by Blue Cross: SBR01 S in Loop 2000B if BCBSMA is the Secondary Payer SBR01 P in Loop 2320 for Primary Carrier Payment information CAS segment(s) in Loop 2320 required on Inpatient Institutional Claims AMT segments within Loop 2320 required on all Secondary Claims SVD02 element in Loop 2430 required for all 837 Professional, Dental and Outpatient Institutional Claims CAS segment(s) in Loop 2430 required for all 837 Professional, Dental, and Outpatient Institutional Claims In addition to the data outlined above, providers should also verify that Loop 2330A (Other Subscriber Name) and Loop 2330B (Other Payer Name) are populated with all the required information for the various segments included within these loops. When submitting claims where Medicare is the Primary Payer, BCBSMA requires that SBR09 equals MA (Medicare Part A) or MB (Medicare Part B) within Loop 2320 (Other Subscriber Information). Loop 2000B (SBR01 S) Loop 2320 (SBR01 P) Example: SBR P 01 MB MB Item 837D 837I 837PItem 837D 837I 837P Item 837D 837I 837P Claim level 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 63 Total charges Loop 2300 CLM02 Total paid amount Loop 2320 AMT02 (Where AMT01 D ) Total deductible amount N A Loop 2320 CAS03 (where CAS01 PR and CAS02 1 ) N A Total co- insurance amount N A Loop 2320 CAS03 (where CAS01 PR and CAS02 2 ) N A Line level 837D 837I 837P Line charges Loop 2400 SV302 Loop 2400 SV203 OutPatient Loop 2400 SV102 Line payment 2430 SVD02 Line deductible amount Loop 2430 CAS03 (where CAS01 PR and CAS02 1 ) Line co- insurance amount Loop 2430 CAS03 (where CAS01 PR and CAS02 2 ) Note: If deductible amount and co-insurance amount are both available, do not present them in two CAS segments. Instead, use a single Patient Responsibility CAS segment. A members, 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 64 837 Subscriber claims vs. dependent claims unique identification Segments in the subscriber loop if the claim is for a dependent. You must submit a 2010BA loop with the actual subscriber of the Blue Cross policy for all claims submitted regardless of whether the services are for the subscriber or for a dependent. Because we do not issue unique identification numbers to all Blue Cross members, we require that the 2010BA loop (subscriber name) be used when submitting subscriber only claims along with the demographic segments for the subscriber of the policy. When submitting claims for a dependent of the subscriber, you must also submit the 2010CA loop along with the dependent demographic segments (do not submit the demographic segments in the subscriber loop if the claim is for a dependent). You must submit a 2010BA loop with the actual subscriber of the BCBS policy in loop 2010BA for all claims submitted to Blue Cross regardless of if the services are for the subscriber or the subscriber s dependent (spouse, child, etc.). 837 Atypical providers The NM108 and NM109 elements within specific loops that refer to NPI enumeration will not be used because most atypical providers do not have an NPI. Instead, atypical providers should submit their Blue Cross Legacy provider number in element REF02 within the 2010BB loops. Please note that within those loops, element REF01 should equal G2. Instructions are also located in Section 6.1 and Section 6.2 within the 837P and 837I Loop Specific Data tables respectively. Loop Segment used by atypical providers segment name 2010BB REF Billing provider secondary identification 2310B REF (Claim Level) Rendering provider secondary identification 2420A REF (Service Line Level) Rendering provider secondary identification Facility code requirements for 837P and 837I claims for Blue Cross The service facility location loop 2310C for Professional and 2310E for Institutional is required when the location where the service was rendered is different than that carried in the 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 65 2010AA (billing provider) or 2010AB (pay-to provider) loops. The service facility location loop (2310E) supplies information of where care was delivered to our member. It is not required for services delivered in the patient s home or for laboratory services. Blue Cross needs only the following data elements for claims adjudication: NM1 FA 2 FACILITY NAME XX 1234567890 NPI of service site in NM109. N3 STREET ADDRESS service site street address, using standard USPO codes. N4 CITY ST ZIPCD service city, state and zip code. Example: NM1 FA 2 GENERAL HOSPITAL XX 1234567890 N3 123 ANY ST N4 ANYTOWN MA 12345 General Information on special billing instructions 837I type of bill (TOB) convention Blue Cross recognizes all NUBC approved type of bill values. However, most claims for our facility partners require only a limited set of these codes. To crosswalk to the acute care hospital Legacy provider identification, we use two significant digits from the TOB as a secondary qualifier to your NPI. This value is taken from your submission in the facility code value of your claim (2300 CLM05-1). For services provided in this area of the hospital Submit this value in the first position of TOB And submit this value in the second position of TOB Inpatient 1 1 Outpatient 1 3 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 66 For services provided in this area of the hospital Submit this value in the first position of TOB And submit this value in the second position of TOB Hospital-based community health center 7 9 Surgical day care 8 3 837I, 837P 837D Provider taxonomy codes Blue Cross does not require taxonomy codes for most claims. However, in certain limited conditions, a taxonomy code is used as a secondary qualifier to your NPI in our crosswalk. Example: 2000A BILLING PROVIDER HIERARCHICAL LEVEL PRV BI PXC 207Q00000X 2310B RENDERING PROVIDER NAME PRV PE PXC 1223G0001X 837I Special billing Instructions for vent beds or complex rehab stays Blue Cross has issued special billing instructions for revenue code use when billing vent beds or complex rehabilitation stays. For services provided in this area of the hospital Please submit this revenue code SNF Vent bed 0129 Complex rehab stays 0139 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 67 Ambulatory surgi-centers (ASC) observation services When billing revenue codes for ASC or observation services, Blue Cross requires that the charge amount for the service must be greater than zero ( 0). Additional information and the most up-to-date billing instructions are available on our Provider Central website at bluecrossma.com provider. 837P Community mental health centers (CMHC) use of procedure code modifiers Blue Cross requires that a CMHC submit a procedure code modifier specific to the specialty of the rendering staff provider on each line of the claim. Blue Cross requires that the billing NPI contracted for community mental health centers also be submitted in the rendering servicing provider loop (2310B or 2420A). Values to enter in the modifier field Modifier Licensure level AF Psychiatrist AH Psychologist AJ Licensed independent clinical social worker HA Child psychiatrist HE Psychiatric nurse practitioner HH Licensed alcohol and drug counselors HI Applied behavioral analysis (ABA) therapist HO Licensed mental health counselor 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 68 HR Licensed marriage family therapist TD Clinical nurse specialist 837P billing instructions for radiology services (professional and technical components) If you are a provider contracted to perform radiology services using the modifiers of 26 (professional) and TC (technical), please bill your claims using these guidelines. You may be contracted to render and bill technical services with your individual NPI or your billing NPI. When billing for On rendering provider line put NPI of the Modifier required Professional component Rendering provider 26 Technical component Provider contracted to render technical services TC Separate bills for professional and technical components For Instructions Modifier Professional component bill Submit the NPI and the tax ID of the billing provider in the 2010AA loop. Submit the NPI (and optionally, the tax ID) of the rendering provider in the 2310B loop. If another provider within the group has rendered another service, submit the NPI of that service rendering provider in the 2420A loop. 26 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 69 For Instructions Modifier Technical component bill Note: to correctly adjudicate the technical component service, you must identify the provider that is contracted with Blue Cross to perform the technical service Submit the NPI and the Tax ID of the billing provider in the 2010AA loop. If the NPI of the billing provider is contracted with Blue Cross to perform the technical service, no other provider loops are required. Our ANSI translator is in accordance with the ANSI standard and will apply the billing provider to each technical service. If your software requires it, you may re-submit the NPI of the billing provider in the rendering (2310B) loop. If the NPI of the billing provider is not contracted with Blue Cross to perform the technical service, submit the NPI (and optionally, the tax ID) of the provider contracted to perform the technical service in the rendering (2310B) loop. TC One bill for professional and technical components To correctly adjudicate the technical component service, you must use the NPI of the provider contracted with Blue Cross as the rendering provider NPI for the technical service. 1. Submit the NPI and the tax ID of the billing provider in the 2010AA loop. 2. The ANSI Standard allows you to submit the NPI of the rendering provider in the 2310B loop. The standard applies that NPI as the rendering provider to all services. Remember, the technical component service (modifier TC) will adjudicate correctly only if the rendering provider is contracted with Blue Cross to provide the technical service. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 70 Option Description Actions 1 Identify the contracted technical component provider in the 2310B loop Submit the NPI (and, optionally, the tax ID) of the provider contracted with Blue Cross to perform the technical service in the rendering (2310B) loop. For each service other than the technical component service, submit the NPI of the rendering provider in the service rendering (2420A) loop. 2 Identify the professional component provider in the 2310B loop Submit the NPI (and, optionally, the tax ID) of the provider rendering the professional component in the rendering (2310B) loop. For the technical component service, submit the NPI of the provider contracted with Blue Cross to render the technical component in the service rendering (2420A) loop. 837P CAA Surprise Billing (Consolidate Appropriations Act) 2022 Federal Mandate Blue Cross requires that a CMHC submit a procedure code modifier specific to the specialty of the rendering staff provider on each line of the claim. Blue Cross requires the following information in the 837P for the 2022 CAA surprise billing mandate: The SERVICE FACILITY LOCATION NAME in loop 2310C is required when billing for professional services rendered by a non-participating provider in a participation facility. The PWK (CLAIM SUPPLEMENTAL INFORMATION) segment in loop 2300 must also be populated using CK (Consent Form) when the member has signed a waiver consent form. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 71 Frequency Codes 5, 7, and 8 Guidelines Frequency code 5 (late charges) Institutional 837I claims You can use frequency 5 code on all claims, except Medicare Advantage claims. A late charge claim request: Applies to one original claim (a 1:1 request) and must include only the additional services and or charges that were not initially included on the original claim. Must follow the same timely filing submission guidelines currently in place for original claims for any newly added services or late charges. Please refer to the Blue Book provider manual for detailed information about timely filing submission guidelines. When to use frequency code 5 When not to use frequency code 5 When adding services that were not billed on the original transaction To add units of service EDI late charge requests require two fields at the loop 2300 level to be coded to process through the Blue Cross claims adjudication system o Claim segment, field CLM05-3 Value 5 indicates a late charge Note: Alpha values are not acceptable for late charges o NTE segment, with qualifier ADD and the narrative that explains what is being added For example: Add 3 new charges and add units of services to CPT or HCPCS code xxx On claims originally denied for exceeding the timely filing limit. Refer to our timely filing appeals guidelines in the Blue Book If the original claim is processed and the late charges exceed the filing limit as outlined in the Blue Book To change the type of bill on either a professional or facility claim, from inpatient to outpatient, or from outpatient to inpatient On an 837P professional claim For claims adjudication resubmission if the claim is rejected on the EDI front-end. You must resubmit this type of claim as a new-day claim with frequency code 1 For subscriber ID corrections. To correct a subscriber ID, please submit a new day claim with frequency code 1 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 72 On Medicare Advantage claims, according to Section 110, Chapter 4 of the CMS Claims Processing Manual. Use frequency code 7 instead 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 73 Frequency code 7 (resubmission) An EDI replacement claim request: Wait for the claim to process and finalize before you submit a replacement. Applies to one original claim (a 1:1 request). You cannot submit one replacement claim for multiple original claims. Must be used to change previously submitted information. Can be used for claims that include changes to the original claim, in addition to charges for services not previously submitted. However, it must meet the timely filing guidelines outlined in the Blue Book provider manual. Requires 3 fields at the loop 2300 level to be coded in order to process through our claims adjudication system. Claim segment, field CLM05-3 Values 7 for Blue Cross replacement requests Note: Alpha values are not acceptable for replacement claims. REF segment, use qualifier value F8. Provide the original claim number to be referenced. This is the claim number that Blue Cross assigned to your original submission. When to use frequency code 7 When not to use frequency code 7 When you have corrected information for the original claim submitted. If in addition to correcting information on the original claim you are adding services that were not billed on the original transaction. Use code 7 to update information in a field on the claim (if only adding late charges, please see separate instructions When appealing or questioning pricing, benefits, or membership coverage dates on a claim. Follow the appeal guidelines in the Blue Book provider manual. On claims originally denied for timely filing. Our Provider Service department manages timely filing appeals. Follow the appeal guidelines in the Blue Book provider manual. For claims originally denied because attachments were not included, or for 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 74 When to use frequency code 7 When not to use frequency code 7 for the use of a frequency code value of 5). When you have corrected information for the original claim submitted. Here are some examples of reasons you may request a payment adjustment: Corrected date of service Revise previously submitted diagnosis codes, procedure, or modifiers Correct patient data, except the Blue Cross Blue Shield of Massachusetts subscriber ID Change the billed amount on the original claim Correct a claim that denied for a referral or authorization, if one has been approved We offer more details in our Replacement claim page on Provider Central, so please be sure to review the guide and share it with your IT team services that require additional documentation for review. When submitting for late charges only. Please see separate instructions for the use of a frequency code value of 5. To change the type of bill on a professional or facility claim from outpatient to inpatient, or from inpatient to outpatient. For claims adjudication and resubmission if the claim is rejected on the EDI front-end. You must resubmit this type of claim as a new-day claim, with claim frequency 1 (CLM05-3). For subscriber ID corrections. To correct a subscriber ID, please submit a new day claim with claim frequency 1 (CLM05-3) referenced. Making changes to the billing NPI. Making changes to a bridged claim. Changing the dates of service if the revised dates fall outside the date span of the original claim. Back to top 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 75 Frequency code 8 (full void) When to use frequency code 8 When not to use frequency code 8 When submitting for a fully voided claim EDI requests require two fields at the loop 2300 level to be coded to process through the Blue Cross claims adjudication system. o Claim segment, field CLM05-3 Value 8 indicates Voided REF 02- Use qualifier value F8- provide original claim number to be referenced. For example Must represent the entire claim not just the line or item that you are retracting. Must serve as a full void of the claim (a 1:1 request). You cannot submit one resubmission claim for multiple original claims. On fully denied claims Exception: sometimes other plans require a full void on a denied claim. This would be done using frequency code 8. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 76 Massachusetts 837 claims for out-of-state Medicaid agencies Effective in April 2016, NPI and NDC fields are systematically required for participating providers. Use the table below to determine which loops are required for 837I and 837P. Field name Loop 837I 837P National drug code 2410 LIN03 X X Rendering provider identifier (NPI) 2310B NM109 unless overridden when reported in loop 2420A NM109 only when rendering is different from loop 2010AA billing provider X Rendering provider identifier (NPI) 2310D NM109 unless overridden when reported in loop 2420C NM109 only when rendering is different from loop 2310A attending Provider X Billing provider NPI 2010AA NM109 X X Billing provider (second) address line 2010AA N302 X X Billing provider middle name or initial 2010AA NM105 X X Billing provider taxonomy code 2000A PRV03 X X Rendering provider taxonomy code 2310B PRV03 unless overridden when reported in loop 2420A PRV03 X Service laboratory or facility postal zone or zip code Loop 2310C N403 unless overridden when reported in loop 2420C N403 X 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 77 Field name Loop 837I 837P Service laboratory or facility postal zone or zip code Loop 2310E N403 X Ambulance transport distance 2300 CR106 unless overridden when reported in loop 2400 CR106 X Ambulance transport distance 2400 SV205 with applicable revenue code X Service laboratory facility name 2310C NM103 unless overridden when reported in loop 2420C NM103 X Service laboratory facility name 2310E N402 X Value code amount 2300 HI in 5th position within the composite data element (value information HI) Up to 24 value codes may be reported with a corresponding amount X Value code 2300 HI in 2nd position within the composite data element (value information HI) Up to 24 value codes may be reported X Condition code 2300 HI in 2nd position within the composite data element (condition information HI) Up to 24 condition codes may be reported X X Occurrence codes and dates 2300 HI in 2nd and 4th positions within the composite data element (occurrence information HI) Up to 24 occurrence codes and associated dates may be reported X 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 78 Field name Loop 837I 837P Occurrence span codes and dates 2300 HI in 2nd and 4th positions within the composite data element (occurrence span information HI) Up to 24 occurrence codes and associated dates may be reported X Referring provider identifier and identification code qualifier 2310A NM108 09 or REF01 02 unless overridden when reported in loop 2420F NM108 09 or REF01 02 X Referring provider identifier and identification code qualifier 2310F NM108 09 or REF01 02 unless overridden when reported in loop 2420D NM108 09 or REF01 02 X Attending provider NPI 2310A NM109 X Operating physician NPI 2310B NM109 unless overridden when reported in loop 2420A NM108 09 X Claim or line note text 2300 NTE02 unless overridden when reported in loop 2400 NTE02 (Line Note NTE) X X Certification condition applies indicator and condition indicator (Early and periodic screening diagnosis and treatment (EPSDT) 2300 CRC02, CRC03 (EPSDT Referral CRC) loop 2300 CRC04 and CRC05 are used when additional conditions apply X X Service facility name and location Information 2310E X Ambulance transport information patient weight ambulance transport 2300 CR102 X 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 79 Field name Loop 837I 837P Reason code round trip purpose description stretcher purpose description CR104 CR109 CR110 X Ordering provider identifier and identification code qualifier 2420E NM108 09 or REF01 02 when a different from the service line rendering provider X Remittance date There are two options for the remittance date. It can either be on the claim level (2330B) or on the line level (2430). We typically see inpatient institutional remittance date on the claim level (2330B) and outpatient professional on the line level (2430). A good practice when you re building an MOA segment is to pass the remit date in the 2430 loop. If you are building an MIA segment, then pass it in the 2330B loop. DTP01 573 DTP02 D8 DTP03 CCYYMMDD (Adjudication or Payment Date) Non-specific procedure codes require a narrative in service detail loop For non-specific procedure codes, HIPAA requires a narrative to be submitted in the narrative field in the service line loop segment for the appropriate transaction: 837I, 837P, or 837D. If the narrative is not submitted for the non-specific procedure codes, the claim will reject back to the submitter stating that the sub-element for the narrative field is missing. Back to top 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 80 Revision history Version Date Updates made 1.2 Apr 2010 Update 837P billing instructions for professional and technical components for radiology services Enhance batch and claim submission guidelines. 1.2.1 Sep 30, 2011 Cover replaced: HIPAA Transaction with Health Care Claim 1.2.1a Nov 1, 2011 8.1 Corrected Loop 2320 to Loop 2430 for line deductible amount and line co-insurance amount items in Blue Cross Blue Shield of Massachusetts Coordination of Benefits Quick Reference table. 5.4 Added NEW section 5.4 Delimiters 1.2.2 Feb 3, 2012 Added new section 6 Blue Cross Identification Number Requirements 7.1 Loop Specific Data Added note to Loop 2310B (rendering provider name) with specific instructions 7.2 Loop Specific Data Added new Loop 2310D (rendering provider name) with specific instructions 7.2 Loop Specific Data HI Segment updated with language to include DTP segment (DTP01 435) if patient s reason for visit is submitted on transaction 7.2 Loop Specific Data HI Segment (present on admission) added to clarify differences between 5010 and 5010 submission. 10.1 Added new section 10.1 Medicare as primary payer 1.2.3 May 15, 2012 7.2 Loop Specific Data 2010BA NM1 revised for clarification. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 81 Version Date Updates made 10.2 Reworded paragraph to clarify submitter vs. dependent claims. 1.2.4 Jan 21, 2013 9 updated to include the requirement of remaining liability Amount (AMT EAF) segment when line level adjudication information is not included 1.2.5 Nov 19, 2015 Update 837P 837I billing instructions for frequency codes 5 (late charges) 7 (resubmissions) Update 837P 837I billing instructions for in-state participating providers and submission of Medicaid out-of-state agency claims 1.2.6 Mar 2016 Updated for plain language and consistent formatting 1.3 May 22, 2017 Throughout: corrected numbering (eliminated x.1 numbers; subsections under introduction began with x.2 ) 1.3 Revised 2.2 Removed the type of file transmission, Broadcast messages 2.4 Updated NEHEN section with Trizetto NEHEN information 5.8 Added new section 8.2 Corrected code by removing extra X in 005010X222A1 (Professional Implementation Guide plus Addenda) 8.2 For Service Facility Location, added the note If the NPI is not different then the NPI submitted in 2010AA do not send the NPI in this loop. For NM101 98 8.2.1 Corrected code by removing extra X in 005010X223A2 (Institutional Implementation Guide plus Addenda) 8.2.1 0 New table for Rendering Provider 12 New section 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 82 Version Date Updates made 13 New section 1.3.1 Mar 1, 2018 9.1 Updated to include information on COB Medicare submission of electronic claims 10.2 Revised Frequency 5 information 10.3 Revised Frequency 7 information 1.3.2 May 22, 2019 10.4 Added Frequency 8 information 1.3.3 November 10, 2021 New template. Removed numbering. Minor language updates. Added section, 837P CAA Surprise Billing (Consolidate Appropriations Act) 2022 Federal Mandate 1.4 February 10, 2023 Added Please note: Your organization s SFTP folder will be created using your submitter; for example, e: company tradingpartners (submitter id). This folder path will be shared with your organization to first Tumbleweed bullet on page 11. 1.5 February 28, 2024 Clarified the section, Facility code requirements for 837P and 837I claims for Blue Cross Back to top | /kaggle/input/edi-db-835-837/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_1 |
Stedi maintains this guide based on public documentation from Anthem. Contact Anthem for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment Advice (X221A1) X12 Release 5010 Revised March 1, 2024 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution. Delimiters Segment Element Component Repetition View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view anthem health-care-claim-paymentadvice- x221a1 01HQWPEZE89AKHP7SZ7YAE893C POWERED BY Build EDI implementation guides at stedi.com 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 1 127 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0100 Transaction Set Header Max use 1 Required BPR 0200 Financial Information Max use 1 Required TRN 0400 Reassociation Trace Number Max use 1 Required CUR 0500 Foreign Currency Information Max use 1 Optional REF 0600 Receiver Identification Max use 1 Optional REF 0600 Version Identification Max use 1 Optional DTM 0700 Production Date Max use 1 Optional Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional Detail Header Number Loop LX 0030 Header Number Max use 1 Required TS3 0050 Provider Summary Information Max use 1 Optional TS2 0070 Provider Supplemental Summary Information Max use 1 Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 2 127 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Corrected Patient Insured Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Insured Name Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional REF 0400 Rendering Provider Identification Max use 10 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Statement From or To Date Max use 2 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 3 127 Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 4 127 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250130 1720 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 5 127 Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 6 127 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 7 127 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HP XXXXXXX XXXXX 20250130 1846 0000 X 005010X2 21A1 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 8 127 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X221A1 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 9 127 Heading ST 0100 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 835 0001 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 10 127 BPR 0200 Heading BPR Financial Information To indicate the beginning of a Payment Order Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and or information from payer to payee to occur Usage notes Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPR D 00000 C CHK CTX 01 XXXXX DA XXX XXXXXXXXX X XXXXXXXXX 01 XXXXXXXX SG XXX 20250130 If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Sender DFI Identifier (BPR-07) is present, then the other is required If Account Number Qualifier (BPR-08) is present, then Sender Bank Account Number (BPR-09) is required If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-12) or Receiver or Provider Bank ID Number (BPR-13) is present, then the other is required If Account Number Qualifier (BPR-14) is present, then Receiver or Provider Account Number (BPR-15) is required Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties C Payment Accompanies Remittance Advice Use this code to instruct your third party processor to move both funds and remittance detail together through the banking system. D Make Payment Only Use this code to instruct your third party processor to move only funds through the banking system and to ignore any remittance information. H Notification Only Use this code when the actual provider payment (BPR02) is zero and the transaction is not being used for Prenotification of Future Transfers. This indicates remittance information without any associated payment. I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. P Prenotification of Future Transfers This code is used only by the payer and the banking system to initially validate account numbers before beginning an EFT relationship. Contact your VAB for additional information. U Split Payment and Remittance Use this code to instruct the third party processor to split the payment and remittance detail, and send each on a separate path. X Handling Party's Option to Split Payment and Remittance Use this code to instruct the third party processor to move the payment and remittance detail, either together or separately, based upon end point requests or capabilities. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 11 127 BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount BPR02 specifies the payment amount. Usage notes Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). BPR-03 478 Credit or Debit Flag Code Identifier (ID) Required Code indicating whether amount is a credit or debit C Credit Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment. D Debit Use this code to indicate a debit to the payer's account and a credit to the provider's account, initiated by the provider at the instruction of the payer. Extreme caution must be used when using Debit transactions. Contact your VAB for information about debit transactions. The rest of this segment and document assumes that a credit payment is being used. BPR-04 591 Payment Method Code Identifier (ID) Required Code identifying the method for the movement of payment instructions ACH Automated Clearing House (ACH) Use this code to move money electronically through the ACH, or to notify the provider that an ACH transfer was requested. When this code is used, see BPR05 through BPR15 for additional requirements. BOP Financial Institution Option Use this code to indicate that the third party processor will choose the method of payment based upon end point requests or capabilities. When this code is used, see BPR05 through BPR15 for additional requirements. CHK Check Use this code to indicate that a check has been issued for payment. FWT Federal Reserve Funds Wire Transfer - Nonrepetitive Use this code to indicate that the funds were sent through the wire system. When this code is used, see BPR05 through BPR15 for additional requirements. NON Non-Payment Data Use this code when the Transaction Handling Code (BPR01) is H, indicating that this is information only and no dollars are to be moved. BPR-05 812 Payment Format Code Identifier (ID) Optional Code identifying the payment format to be used CCP Cash Concentration Disbursement plus Addenda (CCD ) (ACH) 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 12 127 Use the CCD format to move money and up to 80 characters of data, enough to reassociate dollars and data when the dollars are sent through the ACH and the data is sent on a separate path. The addenda must contain a copy of the TRN segment. CTX Corporate Trade Exchange (CTX) (ACH) Use the CTX format to move dollars and data through the ACH. The CTX format can contain up to 9,999 addenda records of 80 characters each. The CTX encapsulates the complete 835 and all envelope segments. BPR-06 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) When using this transaction set to initiate a payment, all or some of BPR06 through BPR16 may be required, depending on the conventions of the specific financial channel being used. BPR06 and BPR07 relate to the originating depository financial institution (ODFI). Usage notes BPR06 through BPR09 relate to the originating financial institution and the originator's account (payer). 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. 04 Canadian Bank Branch and Institution Number BPR-07 507 Sender DFI Identifier Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution sending the transaction into the applicable network. BPR-08 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR08 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR09. DA Demand Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order. Usage notes 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 13 127 Use this number for the originator's account number at the financial institution. BPR-10 509 Payer Identifier Min 10 Max 10 String (AN) Optional A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. BPR10 shall be mutually established between the originating depository financial institution (ODFI) and the company originating the payment. BPR-11 510 Originating Company Supplemental Code Min 9 Max 9 String (AN) Optional A code defined between the originating company and the originating depository financial institution (ODFI) that uniquely identifies the company initiating the transfer instructions Usage notes Use this code to further identify the payer by division or region. The element must be left justified and space filled to meet the minimum element size requirements. If used, this code must be identical to TRN04, excluding trailing spaces. BPR-12 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) BPR12 and BPR13 relate to the receiving depository financial institution (RDFI). Usage notes BPR12 through BPR15 relate to the receiving financial institution and the receiver's account. 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. 04 Canadian Bank Branch and Institution Number BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution receiving the transaction from the applicable network. BPR-14 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR14 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR15. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 14 127 DA Demand Deposit SG Savings BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR15 is the account number of the receiving company to be debited or credited with the payment order. Usage notes Use this number for the receiver's account number at the financial institution. BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). Usage notes Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is NON', enter the date of the 835. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 15 127 TRN 0400 Heading TRN Reassociation Trace Number To uniquely identify a transaction to an application Usage notes This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. Example TRN 1 XXXXXX XXXXXXXXXX X Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN02 provides unique identification for the transaction. Usage notes This number must be unique within the sender receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non- payment 835, this must be a unique remittance advice identification number. See 1.10.2.3, Reassociation of Dollars and Data, for additional information. TRN-03 509 Payer Identifier Min 10 Max 10 String (AN) Required A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. TRN03 identifies an organization. Usage notes This must be a 1 followed by the payer's EIN (or TIN). TRN-04 127 Originating Company Supplemental Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN04 identifies a further subdivision within the organization. Usage notes 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 16 127 If both TRN04 and BPR11 are used, they must be identical, excluding trailing spaces. Since BPR11 has a min max value of 9 9, whenever both are used, this element is restricted to a maximum size of 9. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 17 127 CUR 0500 Heading CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes When the CUR segment is not present, the currency of payment is defined as US dollars. Required when the payment is not being made in US dollars. If not required by this implementation guide, do not send. Example CUR PR XXX Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 18 127 REF 0600 Heading REF Receiver Identification To specify identifying information Usage notes This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee. Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example REF EV XX Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 19 127 REF 0600 Heading REF Version Identification To specify identifying information Usage notes Update this reference number whenever a change in the version or release number affects the 835. (This is not the ANSI ASCX12 version number as reported in the GS segment.) Required when necessary to report the version number of the adjudication system that generated the claim payments in order for the payer to resolve customer service questions from the payee. If not required by this implementation guide, do not send. Example REF F2 XX Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 20 127 DTM 0700 Heading DTM Production Date To specify pertinent dates and times Usage notes If your adjudication cycle completed on Thursday and your 835 is produced on Saturday, you are required to populate this segment with Thursday's date. Required when the cut off date of the adjudication system remittance run is different from the date of the 835 as identified in the related GS04 element. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example DTM 405 20250130 Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes Report the end date for the adjudication production cycle for claims included in this 835. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 21 127 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading Payer Identification Loop N1 Payer Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information for the payer. The payer's secondary identifying reference number is provided in N104, if necessary. Example N1 PR XX XV XX If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). N1-04 67 Payer Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 22 127 N3 1000 Heading Payer Identification Loop N3 Payer Address To specify the location of the named party Example N3 XXX XXXXX Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 23 127 N4 1100 Heading Payer Identification Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXX XX XXXXXXXX XX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 24 127 REF 1200 Heading Payer Identification Loop REF Additional Payer Identification To specify identifying information Usage notes The ID available in the TRN and N1 segments must be used before using the REF segment. Required when additional payer identification numbers beyond those in the TRN and Payer N1 segments are needed. If not required by this implementation guide, may be sent at sender's discretion, but cannot be required by the receiver. Example REF 2U XXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number For Medicare carriers or intermediaries, use this qualifier for the Medicare carrier or intermediary ID number. For Blue Cross and Blue Shield Plans, use this qualifier for the Blue Cross Blue Shield association plan code. EO Submitter Identification Number This is required when the original transaction sender is not the payer or is identified by an identifier other than those already provided. This is not updated by third parties between the payer and the payee. An example of a use for this qualifier is when identifying a clearinghouse that created the 835 when the health plan sent a proprietary format to the clearinghouse. HI Health Industry Number (HIN) NF National Association of Insurance Commissioners (NAIC) Code This is the preferred value when identifying the payer. REF-02 127 Additional Payer Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 25 127 PER 1300 Heading Payer Identification Loop PER Payer Business Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send. Example PER CX XXX TE XXXX TE X EX XXXXXX Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 26 127 PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 27 127 PER 1300 Heading Payer Identification Loop PER Payer Technical Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required to report technical contact information for this remittance advice. Example PER BL XXXXX EM XXX EM XXXXXX FX XXX Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail TE Telephone Recommended UR Uniform Resource Locator (URL) Use only when there is no central telephone number for the payer entity. PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 28 127 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile TE Telephone UR Uniform Resource Locator (URL) PER-06 364 Payer Technical Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile UR Uniform Resource Locator (URL) PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 29 127 1000A Payer Identification Loop end PER 1300 Heading Payer Identification Loop PER Payer WEB Site To identify a person or office to whom administrative communications should be directed Usage notes Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PER IC UR XXX Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 30 127 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading Payee Identification Loop N1 Payee Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information of the payee. The identifying reference number is provided in N104. Example N1 PE XX XV XXXXX Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). This only applies in cases of post payment recovery. See section 1.10.2.16 (Post Payment Recovery) for further information. XX Centers for Medicare and Medicaid Services National Provider Identifier This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate. N1-04 67 Payee Identification Code Min 2 Max 80 String (AN) Required Code identifying a party or other code This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 31 127 N3 1000 Heading Payee Identification Loop N3 Payee Address To specify the location of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N3 XXXX XX Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 32 127 N4 1100 Heading Payee Identification Loop N4 Payee City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N4 XXXXXXX XX XXXXX XX Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 33 127 REF 1200 Heading Payee Identification Loop REF Payee Additional Identification To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example REF D3 XXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number D3 National Council for Prescription Drug Programs Pharmacy Number PQ Payee Identification REF-02 127 Additional Payee Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 34 127 RDM 1400 Heading Payee Identification Loop RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes Required when BPR01 U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM OL X X Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 35 127 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 36 127 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 00 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 | /kaggle/input/edi-db-835-837/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_0 |
50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 34 127 RDM 1400 Heading Payee Identification Loop RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes Required when BPR01 U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM OL X X Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 35 127 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 36 127 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 00 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 37 127 TS3 0050 Detail Header Number Loop TS3 Provider Summary Information To supply provider-level control information Usage notes TS301 identifies the subsidiary provider. The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000. Required for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity i.e., the corporate office of a hospital chain. If not required by this implementation guide, do not send. Example TS3 XXXXX XX 20250130 00000000 000000 0000 0000000 0000000000 0000 0000000000000 00000000 000 0000000 000000000 0000 00000000000 Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes When reporting a TS3 segment for professional claims and the claims are not all for the same place of service, report a place of service of 11 (Office) as the default value. When reporting a TS3 segment for pharmaceutical claims and the claims are not all for the same place of service, report a place of service of 99 (Other unlisted facility) as the default value. TS3-03 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year TS303 is the last day of the provider's fiscal year. Usage notes 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 38 127 Use this date for the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known, use December 31st of the current year. TS3-04 380 Total Claim Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity TS304 is the total number of claims. Usage notes This is the total number of claims. TS3-05 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount TS305 is the total of reported charges. Usage notes This is the total reported charges for all claims. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all 782 elements. TS3-13 782 Total MSP Payer Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS313 is the total Medicare Secondary Payer (MSP) primary payer amount. Usage notes See TR3 note 3. TS3-15 782 Total Non-Lab Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS317 is the Health Care Financing Administration Common Procedural Coding System (HCPCS) reported charges. Usage notes See TR3 note 3. TS3-18 782 Total HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 39 127 Monetary amount TS318 is the total Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes See TR3 note 3. TS3-20 782 Total Professional Component Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS320 is the total professional component amount. Usage notes The professional component amount must also be reported in the CAS segment with a Claim Adjustment Reason Code value of 89. See TR3 note 3. TS3-21 782 Total MSP Patient Liability Met Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS321 is the total Medicare Secondary Payer (MSP) patient liability met. Usage notes See TR3 note 3. TS3-22 782 Total Patient Reimbursement Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS322 is the total patient reimbursement. Usage notes See TR3 note 3. TS3-23 380 Total PIP Claim Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS323 is the total periodic interim payment (PIP) number of claims. Usage notes See TR3 note 3. TS3-24 782 Total PIP Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 40 127 See TR3 note 3. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 41 127 TS2 0070 Detail Header Number Loop TS2 Provider Supplemental Summary Information To provide supplemental summary control information by provider fiscal year and bill type Usage notes This segment provides summary information specific to an iteration of the LX loop (Table 2). Each element represents the total value for the provider bill type combination in this loop 2000 iteration. Required for Medicare Part A. If not required by this implementation guide, do not send. Example TS2 00000000 00000 0000 0000000 0000000000000 000 0000000000 000000000 0000 00000000000000 0000 000 000000000000 0 00000000 0000 00000000000 000 00 0 0000000000 0000000000 Max use 1 Optional TS2-01 782 Total DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS201 is the total diagnosis related group (DRG) amount. Usage notes This includes: operating federal-specific amount, operating hospital-specific amount, operating Indirect Medical Education amount, and operating Disproportionate Share Hospital amount. It does not include any operating outlier amount. See TR3 note 2. TS2-02 782 Total Federal Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS202 is the total federal specific amount. Usage notes See TR3 note 2. TS2-03 782 Total Hospital Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS203 is the total hospital specific amount. Usage notes See TR3 note 2. TS2-04 782 Total Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS204 is the total disproportionate share amount. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 42 127 Usage notes See TR3 note 2. TS2-05 782 Total Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS205 is the total capital amount. Usage notes This includes: capital federal-specfic amount, hospital federal-specfic amount, hold harmless amount, Indirect Medical Education amount, Disproportionate Share Hospital amount, and the exception amount. It does not include any capital outlier amount. See TR3 note 2. TS2-06 782 Total Indirect Medical Education Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS206 is the total indirect medical education amount. Usage notes See TR3 note 2. TS2-07 380 Total Outlier Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS207 is the total number of outlier days. Usage notes See TR3 note 2. TS2-08 782 Total Day Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS208 is the total day outlier amount. Usage notes See TR3 note 2. TS2-09 782 Total Cost Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS209 is the total cost outlier amount. Usage notes See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 43 127 TS210 is the diagnosis related group (DRG) average length of stay. Usage notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS211 is the total number of discharges. Usage notes This is the discharge count produced by PPS PRICER SOFTWARE. See TR3 note 2. TS2-12 380 Total Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS212 is the total number of cost report days. Usage notes See TR3 note 2. TS2-13 380 Total Covered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS213 is the total number of covered days. Usage notes See TR3 note 2. TS2-14 380 Total Noncovered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS214 is total number of non-covered days. Usage notes See TR3 note 2. TS2-15 782 Total MSP Pass-Through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer. Usage notes See TR3 note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 44 127 Numeric value of quantity TS216 is the average diagnosis-related group (DRG) weight. Usage notes See TR3 note 2. TS2-17 782 Total PPS Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS217 is the total prospective payment system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-18 782 Total PPS Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-19 782 Total PPS DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 45 127 2100 Claim Payment Information Loop Max 1 Required CLP 0100 Detail Header Number Loop Claim Payment Information Loop CLP Claim Payment Information To supply information common to all services of a claim Usage notes For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations. Example CLP XX 20 0000000000000 000000000 0000000000000 0 MA X XX X XX 00000000 0000 Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format). CLP-02 1029 Claim Status Code Identifier (ID) Required Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization Usage notes To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code. 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied Usage of this code would apply if the Patient Subscriber is not recognized, and the claim was not forwarded to another payer. 19 Processed as Primary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 20 Processed as Secondary, Forwarded to Additional Payer(s) 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 46 127 When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 22 Reversal of Previous Payment See section 1.10.2.8 for usage information. 23 Not Our Claim, Forwarded to Additional Payer(s) Usage of this code would apply if the patient subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required. 25 Predetermination Pricing Only - No Payment CLP-03 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CLP-04 782 Claim Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 47 127 Code identifying type of claim Usage notes For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2- 005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835. The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer. 12 Preferred Provider Organization (PPO) This code is also used for Blue Cross Blue Shield participating provider arrangements. 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance This code is also used for Blue Cross Blue Shield non-participating provider arrangements. 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical CH Champus DS Disability HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use this code for the Black Lung Program. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 48 127 Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 49 127 CAS 0200 Detail Header Number Loop Claim Payment Information Loop CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note 1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CAS PR XX 00 000 X 000000000000000 000000000000 0 XXXXX 00000 00000000000 XXX 0 00 X 000000000000 000 00000000000 XXX 0000000 0000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 50 127 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 51 127 A positive value decreases the covered days, and a negative number increases the covered days. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 52 127 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 53 127 Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 54 127 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Patient Insured Name To supply the full name of an individual or organizational entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send. Example NM1 74 1 XXX XX X XXX C XXX Variants (all may be used) NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 74 Corrected Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 55 127 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 56 127 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1 PR 2 XXXXXX FI XXXXXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 57 127 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 58 127 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1 TT 2 XXXXXX FI XXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 59 127 PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Crossover Carrier Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 60 127 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Insured Name To supply the full name of an individual or organizational entity Usage notes In the case of Medicare and Medicaid, the insured patient is always the subscriber and this segment is not used. Required when the original claim reported the insured or subscriber (for example 837 2010BA loop Subscriber Name NM1 Segment) that is different from the patient. If not required by this implementation guide, do not send. This segment contains the same information as reported on the claim (for example 837 2010BA loop Subscriber Name NM1 Segment when the patient was reported in the 2010CA loop Patient Name NM1 Segment). Example NM1 IL 2 XXXX X XXX XXXXXX II XXXXXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 61 127 Individual middle name or initial Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes For example, use when necessary to differentiate between a Junior and Senior under the same contract. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number The code MI is intended to identify that the subscriber's identification number as assigned by the payer will be conveyed in NM109. Payers use different terminology to convey the same number, therefore, the 835 workgroup recommends using MI (Member Identification number) to convey the same categories of numbers as represented in the 837 IGs for the inbound claims. NM1-09 67 Subscriber Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 62 127 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1 GB 1 XXX XXX XXXX XXXXXX MI XXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 63 127 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 64 127 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1 QC 1 XX XXXXXX XXXX XXXXXX II XXXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 65 127 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) HN Health Insurance Claim (HIC) Number II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number MR Medicaid Recipient Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 66 127 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1 82 2 XXXX XXX XXXX XXXXX SL XXXXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 67 127 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 68 127 MIA 0330 Detail Header Number Loop Claim Payment Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment | /kaggle/input/edi-db-835-837/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_1 |
health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 66 127 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1 82 2 XXXX XXX XXXX XXXXX SL XXXXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 67 127 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 68 127 MIA 0330 Detail Header Number Loop Claim Payment Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA 00 0000 00 000000000 XXXXX 00 000 0000000000 0 0000 0000 00000 00000 000000000000000 000000000 0 0000 00000 00000000000 000000000000000 0 XXXX X XX X XXXXXX 000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 69 127 Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 70 127 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 71 127 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 72 127 MOA 0350 Detail Header Number Loop Claim Payment Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA 0000000000 00000000 XXXXXX XXXX XXXXXX XXXX X XXXX 0000000 000000000000000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 73 127 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 74 127 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REF 1W X Variants (all may be used) REF Rendering Provider Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number Use this code when conveying the Group Number in REF02. 1W Member Identification Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known. 9A Repriced Claim Reference Number 9C Adjusted Repriced Claim Reference Number 28 Employee Identification Number BB Authorization Number Use this qualifier only when supplying an authorization number that was assigned by the adjudication process and was not provided prior to the services. Do not use this qualifier when reporting the same number as reported in the claim as the prior authorization or pre-authorization number. CE Class of Contract Code See section 1.10.2.15 for information on the use of Class of Contract Code. EA Medical Record Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. G1 Prior Authorization Number Use this qualifier when reporting the number received with the original claim as a pre- authorization number (in the 837 that was at table 2, position 180, REF segment, using the same qualifier of G1). G3 Predetermination of Benefits Identification Number IG Insurance Policy Number Use this code when conveying the Policy Number in REF02. REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 75 127 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 76 127 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Rendering Provider Identification To specify identifying information Usage notes The NM1 segment always contains the primary reference number. Required when additional rendering provider identification numbers not already reported in the Provider NM1 segment for this claim were submitted on the original claim and impacted adjudication. If not required by this implementation guide, do not send. Example REF 0B XX Variants (all may be used) REF Other Claim Related Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 77 127 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM 050 20250130 Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 78 127 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM 036 20250130 Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 79 127 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 232 20250130 Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 80 127 PER 0600 Detail Header Number Loop Claim Payment Information Loop PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PER CX XXX TE XXXXX EX XXXXXX EX XX If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 81 127 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 82 127 AMT 0620 Detail Header Number Loop Claim Payment Information Loop AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT D8 00 Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). D8 Discount Amount Prompt Pay Discount Amount See section 1.10.2.9 for additional information. DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. T Tax T2 Total Claim Before Taxes Used only when tax also applies to the claim. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 83 127 Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 84 127 QTY 0640 Detail Header Number Loop Claim Payment Information Loop QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTY PS 000000000 Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual LE Life-time Reserve - Estimated NE Non-Covered - Estimated NR Not Replaced Blood Units OU Outlier Days PS Prescription VS Visits ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 85 127 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78 25 ). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVC ER XX XX XX XX XX 000000000 00000000000 XX 00 0 IV XXX XX XX XX XX XXX 00000000000000 Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 86 127 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format N6 National Health Related Item Code in 4-6 Format This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names National Health Related Item Code in 4-6 Format Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. NU National Uniform Billing Committee (NUBC) UB92 Codes UI U.P.C. Consumer Package Code (1-5-5) This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names U.P.C. Consumer Package Code (1-5-5) Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. WK Advanced Billing Concepts (ABC) Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used in transactions covered under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 87 127 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier Max use 1 Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 88 127 To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes WK Advanced Billing Concepts (ABC) Codes This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 89 127 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 90 127 DTM 0800 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 150 20250130 Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 91 127 CAS 0900 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS OA XXXX 00000000000 0000000 XXXX 000000000000 000 0000000000 X 000000000000000 0000 XXXXX 00000 0000000000 000000000 XXX 0000000 000000000000 XX X 0000 000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 92 127 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 93 127 A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 94 127 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 95 127 Usage notes See CAS02. CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 96 127 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF 0K X Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form | /kaggle/input/edi-db-835-837/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_2 |
CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 95 127 Usage notes See CAS02. CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 96 127 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF 0K X Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 97 127 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF 6R XXX Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 98 127 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REF 1H X Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 99 127 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REF G1 X Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification BB Authorization Number E9 Attachment Code G1 Prior Authorization Number G3 Predetermination of Benefits Identification Number LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 100 127 AMT 1100 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT ZL 00 Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction T Tax T2 Total Claim Before Taxes Use this monetary amount for the service charge before taxes. This is only used when there is an applicable tax amount on this service. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 101 127 QTY 1200 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTY ZK 0 Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 102 127 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQ RX XXXX Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes RX National Council for Prescription Drug Programs Reject Payment Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 103 127 Summary PLB 0100 Summary PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLB XXX 20250130 LE XXXXX 0000000000 XX XX 0000 0 XX X 0000000000000 XX X 0000000000 XX XXXX 0 X X X 000 If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use 1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 104 127 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AH Origination Fee This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims. AM Applied to Borrower's Account See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this code to identify the loan repayment amount. This is capitation specific. AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 105 127 BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CR Capitation Interest This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CS Adjustment Provide supporting identification information in PLB03-2. CT Capitation Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CV Capital Passthru CW Certified Registered Nurse Anesthetist Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. FC Fund Allocation This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund must be identified in PLB03-2. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 106 127 Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source). C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Use when necessary to assist the receiver in identifying, tracking or reconcilling the adjustment. See sections 1.10.2.10 (Capitation and Related Payments), 1.10.2.5 (Advanced Payments and Reconciliation) and 1.10.2.12 (Balance Forward Processing) for further information. PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PLB04 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. PLB-05 C042 Adjustment Identifier Max use 1 Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 107 127 To provide the category and identifying reference information for an adjustment - PLB05 is the adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB06 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-07 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB07 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-08 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB08 is the adjustment amount. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 108 127 Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-09 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-10 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB10 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-11 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB11 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 109 127 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-12 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB12 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-13 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB13 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 110 127 Summary end SE 0200 Summary SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 000000 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 111 127 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 000 000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 112 127 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 00 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 113 127 EDI Samples Example 1: Dollars and Data Sent Separately ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 012345678 X 005010X221A1 ST 835 112233 BPR I 1100 C ACH CCP 01 888999777 DA 24681012 1935665544 01 111333555 DA 144444 20190316 TRN 1 71700666555 1935665544 DTM 405 20190314 N1 PR RUSHMORE LIFE N3 10 SOUTH AVENUET N4 RAPID CITY SD 55111 PER BL JOHN WAYNE TE 8005551212 EX 123 N1 PE ACME MEDICAL CENTER XX 5544667733 REF 0B 777667755 LX 1 CLP 5554555444 1 800 500 300 12 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT AU 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 12 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT AU 1200 SVC HC 93555 1200 600 DTM 472 20190310 CAS PR 1 600 AMT B6 1200 SE 26 112233 GE 1 012345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 114 127 Example 2: Multiple Claims Single Check ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1512345678 REF EV XYZ CLEARINGHOUSE N1 PR DENTAL OF ABC N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC XX 9999947036 REF 0B 212121212 LX 1 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 DOE SANDY MI SJD11112 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 119 74 12 119932404007801 11 1 NM1 QC 1 DOE SALLY MI SJD11111 NM1 IL 1 DOE JOHN MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 74 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 12 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 115 127 AMT B6 25 SVC AD D0220 25 0 DTM 472 20190324 CAS PR 3 14 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 0 DTM 472 20190324 CAS PR 3 10 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 1145 14 902 12 119932404007801 11 1 NM1 QC 1 SMITH SAM MI SJD11116 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 14 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D2790 940 0 DTM 472 20190324 CAS PR 3 756 CAS CO 45 184 SVC AD D2950 180 0 DTM 472 20190324 CAS PR 3 146 CAS CO 45 34 CLP 7722337 1 348 16.8 44.2 12 119932404007801 11 1 NM1 QC 1 JONES SAM MI SJD11122 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 28 SVC AD D4342 125 0 DTM 472 20190313 CAS CO 45 125 SVC AD D4381 43 0 DTM 472 20190313 CAS PR 3 33 CAS CO 45 10 SVC AD D2950 180 16.8 DTM 472 20190313 CAS PR 3 11.2 CAS CO 45 152 AMT B6 28 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 JONES SALLY MI SJD11133 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190321 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 116 127 DTM 472 20190321 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190321 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190321 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190321 CAS CO 45 24 AMT B6 49 CLP 7722337 1 179 108 12 119932404007801 11 1 NM1 QC 1 DOE SAM MI SJD99999 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 108 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 129 82 12 119932404007801 11 1 NM1 QC 1 DOE SUE MI SJD88888 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 CLP 7722337 1 221 144 12 119932404007801 11 1 NM1 QC 1 DOE DONNA MI SJD77777 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 144 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0330 92 62 DTM 472 20190324 CAS CO 45 30 AMT B6 62 SVC AD D1120 54 37 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 117 127 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 SE 183 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 118 127 Example 3: Claim Specific Negotiated Discount ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 132 C CHK 20190331 TRN 1 12345 1512345678 REF EV CLEARINGHOUSE N1 PR DELTA DENTAL OF ABC N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC XV 999994703 LX 1 CLP 7722337 1 226 132 12 119932404007801 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 131 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 131 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 131 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 131 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 131 24 AMT B6 49 SE 35 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 119 127 Example 4: Claim Adjustment Reason Code 45 ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 80.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PATACCT 1 400 80 MC CLAIMNUMBER 11 1 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004074627 AMT AU 150 SVC HC 99213 150 80 1 DTM 472 20190101 CAS CO 45 70 AMT B6 80 SVC HC 85003 100 0 1 DTM 472 20190101 CAS CO 204 100 SVC HC 36415 150 0 1 DTM 472 20190101 CAS CO 97 150 SE 33 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 120 127 Example 5a: Line Service Tax impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 11.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PCN 1 36.20 11.06 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 36.20 SVC HC 99214 26.2 3.06 DTM 472 20170109 CAS CO 45 23.2 137 -.06 REF 6R B1 AMT B6 3 SVC HC 36415 10 8 DTM 472 20170109 CAS CO 45 2 REF 6R B2 AMT B6 8 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 121 127 Example 5b: Line Service Bonuses impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 12.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PCN 1 25 12 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 12 DTM 472 20170109 CAS CO 45 5 161 -2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 122 127 Example 5c: Line Service Penalty impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PCN 1 25 8 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 8 DTM 472 20170109 CAS CO 45 5 B4 2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 123 127 Example 6: Not Covered Not Authorized Inpatient Facility claim days ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8000.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PATACCT 1 40000 8000 MC CLAIMNUMBER 11 1 CAS CO 197 2000 1 45 30000 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 232 20190101 DTM 233 20190105 DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004001212 AMT AU 38000 QTY CA 4 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 124 127 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 120.03 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP 04777796TLC777122 1 155 120.03 13 8838888212 11 1 NM1 QC 1 MASTERS MARVIN L MI 80444444403 NM1 IL 1 CABLE MABEL MI 80444444403 NM1 74 1 MASTERS MARVIN C 80444444401 NM1 82 1 SHELTON MD BLAKE XX 1666666666 REF 1L 28 REF CE HSOAP-LAOA DTM 232 20191114 DTM 233 20181114 DTM 050 20181119 AMT AU 155 SVC HC 99393 155 120.03 1 DTM 472 20181114 CAS CO 45 34.97 REF LU 11 REF 6R 22261822 AMT B6 120.03 SE 34 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 125 127 Example 8b: Claim submitted with incorrect subscriber name and ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 35.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP 02333TLC222222 1 115 35.06 35 13 8333333214 11 1 NM1 QC 1 KEATON ALEX P MI 80000006006 NM1 IL 1 THOMAS JASON MI 80000006006 NM1 74 1 JEROME C 80000006001 NM1 82 1 BLOOD MD RED N XX 1888888886 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191113 DTM 233 20191113 DTM 050 20191119 AMT AU 115 SVC HC 99213 115 35.06 1 DTM 472 20191113 CAS CO 45 44.94 CAS PR 3 35 REF LU 11 REF 6R 22261389 AMT B6 70.06 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 126 127 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 2415.25 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP 05444444TLC999999 1 3903 2415.25 13 8777777782 21 1 NM1 QC 1 GONZALES SAMMY MI 80455555502 NM1 IL 1 LAPLANTE FERN MI 80455555502 NM1 74 1 R NM1 82 1 GOOD MD ROBERT B XX 19999999987 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191101 DTM 233 20191101 DTM 050 20191114 AMT AU 3903 AMT F5 150 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF LU 21 REF 6R 22215592 AMT B6 2415.25 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 127 127 | /kaggle/input/edi-db-835-837/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_3 |
Stedi maintains this guide based on public documentation from X12 HIPAA. Contact X12 HIPAA for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment Advice (X221A1) X12 Release 5010 Revised May 3, 2024 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution. Delimiters Segment Element Component Repetition View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice- x221a1 01GRYB6DS30MGXWBPFZCM3695E POWERED BY Build EDI implementation guides at stedi.com 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 1 128 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0100 Transaction Set Header Max use 1 Required BPR 0200 Financial Information Max use 1 Required TRN 0400 Reassociation Trace Number Max use 1 Required CUR 0500 Foreign Currency Information Max use 1 Optional REF 0600 Receiver Identification Max use 1 Optional REF 0600 Version Identification Max use 1 Optional DTM 0700 Production Date Max use 1 Optional Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional Detail Header Number Loop LX 0030 Header Number Max use 1 Required TS3 0050 Provider Summary Information Max use 1 Optional TS2 0070 Provider Supplemental Summary Information Max use 1 Optional 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 2 128 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Insured Name Max use 1 Optional NM1 0300 Corrected Patient Insured Name Max use 1 Optional NM1 0300 Service Provider Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional REF 0400 Rendering Provider Identification Max use 10 Optional DTM 0500 Statement From or To Date Max use 2 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Claim Received Date Max use 1 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 Service Identification Max use 8 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 3 128 Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 4 128 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250130 0532 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 5 128 Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 6 128 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 7 128 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HP XXXXXXX XXXXXX 20250130 0836 00000 X 005010 X221A1 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 8 128 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X221A1 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 9 128 Heading ST 0100 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 835 0001 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 10 128 BPR 0200 Heading BPR Financial Information To indicate the beginning of a Payment Order Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and or information from payer to payee to occur Usage notes Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPR U 000000 C NON CCP 04 XXXXXXXX DA XXXXXX XXXX XXXXXX XXXXXXXXX 01 XXXXXXX DA X 20250130 If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Sender DFI Identifier (BPR-07) is present, then the other is required If Account Number Qualifier (BPR-08) is present, then Sender Bank Account Number (BPR-09) is required If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-12) or Receiver or Provider Bank ID Number (BPR-13) is present, then the other is required If Account Number Qualifier (BPR-14) is present, then Receiver or Provider Account Number (BPR-15) is required Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties C Payment Accompanies Remittance Advice Use this code to instruct your third party processor to move both funds and remittance detail together through the banking system. D Make Payment Only Use this code to instruct your third party processor to move only funds through the banking system and to ignore any remittance information. H Notification Only Use this code when the actual provider payment (BPR02) is zero and the transaction is not being used for Prenotification of Future Transfers. This indicates remittance information without any associated payment. I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. P Prenotification of Future Transfers This code is used only by the payer and the banking system to initially validate account numbers before beginning an EFT relationship. Contact your VAB for additional information. U Split Payment and Remittance Use this code to instruct the third party processor to split the payment and remittance detail, and send each on a separate path. X Handling Party's Option to Split Payment and Remittance Use this code to instruct the third party processor to move the payment and remittance detail, either together or separately, based upon end point requests or capabilities. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 11 128 BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount BPR02 specifies the payment amount. Usage notes Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). BPR-03 478 Credit or Debit Flag Code Identifier (ID) Required Code indicating whether amount is a credit or debit C Credit Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment. D Debit Use this code to indicate a debit to the payer's account and a credit to the provider's account, initiated by the provider at the instruction of the payer. Extreme caution must be used when using Debit transactions. Contact your VAB for information about debit transactions. The rest of this segment and document assumes that a credit payment is being used. BPR-04 591 Payment Method Code Identifier (ID) Required Code identifying the method for the movement of payment instructions ACH Automated Clearing House (ACH) Use this code to move money electronically through the ACH, or to notify the provider that an ACH transfer was requested. When this code is used, see BPR05 through BPR15 for additional requirements. BOP Financial Institution Option Use this code to indicate that the third party processor will choose the method of payment based upon end point requests or capabilities. When this code is used, see BPR05 through BPR15 for additional requirements. CHK Check Use this code to indicate that a check has been issued for payment. FWT Federal Reserve Funds Wire Transfer - Nonrepetitive Use this code to indicate that the funds were sent through the wire system. When this code is used, see BPR05 through BPR15 for additional requirements. NON Non-Payment Data Use this code when the Transaction Handling Code (BPR01) is H, indicating that this is information only and no dollars are to be moved. BPR-05 812 Payment Format Code Identifier (ID) Optional Code identifying the payment format to be used CCP Cash Concentration Disbursement plus Addenda (CCD ) (ACH) 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 12 128 Use the CCD format to move money and up to 80 characters of data, enough to reassociate dollars and data when the dollars are sent through the ACH and the data is sent on a separate path. The addenda must contain a copy of the TRN segment. CTX Corporate Trade Exchange (CTX) (ACH) Use the CTX format to move dollars and data through the ACH. The CTX format can contain up to 9,999 addenda records of 80 characters each. The CTX encapsulates the complete 835 and all envelope segments. BPR-06 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) When using this transaction set to initiate a payment, all or some of BPR06 through BPR16 may be required, depending on the conventions of the specific financial channel being used. BPR06 and BPR07 relate to the originating depository financial institution (ODFI). Usage notes BPR06 through BPR09 relate to the originating financial institution and the originator's account (payer). 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. 04 Canadian Bank Branch and Institution Number BPR-07 507 Sender DFI Identifier Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution sending the transaction into the applicable network. BPR-08 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR08 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR09. DA Demand Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 13 128 Use this number for the originator's account number at the financial institution. BPR-10 509 Payer Identifier Min 10 Max 10 String (AN) Optional A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. BPR10 shall be mutually established between the originating depository financial institution (ODFI) and the company originating the payment. BPR-11 510 Originating Company Supplemental Code Min 9 Max 9 String (AN) Optional A code defined between the originating company and the originating depository financial institution (ODFI) that uniquely identifies the company initiating the transfer instructions Usage notes Use this code to further identify the payer by division or region. The element must be left justified and space filled to meet the minimum element size requirements. If used, this code must be identical to TRN04, excluding trailing spaces. BPR-12 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) BPR12 and BPR13 relate to the receiving depository financial institution (RDFI). Usage notes BPR12 through BPR15 relate to the receiving financial institution and the receiver's account. 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. 04 Canadian Bank Branch and Institution Number BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution receiving the transaction from the applicable network. BPR-14 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR14 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR15. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 14 128 DA Demand Deposit SG Savings BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR15 is the account number of the receiving company to be debited or credited with the payment order. Usage notes Use this number for the receiver's account number at the financial institution. BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). Usage notes Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is NON', enter the date of the 835. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 15 128 TRN 0400 Heading TRN Reassociation Trace Number To uniquely identify a transaction to an application Usage notes This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. Example TRN 1 X XXXXXXXXXX XXXX Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN02 provides unique identification for the transaction. Usage notes This number must be unique within the sender receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non- payment 835, this must be a unique remittance advice identification number. See 1.10.2.3, Reassociation of Dollars and Data, for additional information. TRN-03 509 Payer Identifier Min 10 Max 10 String (AN) Required A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. TRN03 identifies an organization. Usage notes This must be a 1 followed by the payer's EIN (or TIN). TRN-04 127 Originating Company Supplemental Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN04 identifies a further subdivision within the organization. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 16 128 If both TRN04 and BPR11 are used, they must be identical, excluding trailing spaces. Since BPR11 has a min max value of 9 9, whenever both are used, this element is restricted to a maximum size of 9. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 17 128 CUR 0500 Heading CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes When the CUR segment is not present, the currency of payment is defined as US dollars. Required when the payment is not being made in US dollars. If not required by this implementation guide, do not send. Example CUR PR XXX Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 18 128 REF 0600 Heading REF Receiver Identification To specify identifying information Usage notes This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee. Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example REF EV X Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 19 128 REF 0600 Heading REF Version Identification To specify identifying information Usage notes Update this reference number whenever a change in the version or release number affects the 835. (This is not the ANSI ASCX12 version number as reported in the GS segment.) Required when necessary to report the version number of the adjudication system that generated the claim payments in order for the payer to resolve customer service questions from the payee. If not required by this implementation guide, do not send. Example REF F2 XXXXXX Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 20 128 DTM 0700 Heading DTM Production Date To specify pertinent dates and times Usage notes If your adjudication cycle completed on Thursday and your 835 is produced on Saturday, you are required to populate this segment with Thursday's date. Required when the cut off date of the adjudication system remittance run is different from the date of the 835 as identified in the related GS04 element. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example DTM 405 20250130 Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes Report the end date for the adjudication production cycle for claims included in this 835. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 21 128 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading Payer Identification Loop N1 Payer Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information for the payer. The payer's secondary identifying reference number is provided in N104, if necessary. Example N1 PR X XV XX If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). N1-04 67 Payer Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 22 128 N3 1000 Heading Payer Identification Loop N3 Payer Address To specify the location of the named party Example N3 X XXX Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 23 128 N4 1100 Heading Payer Identification Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXXX XXX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 24 128 REF 1200 Heading Payer Identification Loop REF Additional Payer Identification To specify identifying information Usage notes The ID available in the TRN and N1 segments must be used before using the REF segment. Required when additional payer identification numbers beyond those in the TRN and Payer N1 segments are needed. If not required by this implementation guide, may be sent at sender's discretion, but cannot be required by the receiver. Example REF 2U XXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number For Medicare carriers or intermediaries, use this qualifier for the Medicare carrier or intermediary ID number. For Blue Cross and Blue Shield Plans, use this qualifier for the Blue Cross Blue Shield association plan code. EO Submitter Identification Number This is required when the original transaction sender is not the payer or is identified by an identifier other than those already provided. This is not updated by third parties between the payer and the payee. An example of a use for this qualifier is when identifying a clearinghouse that created the 835 when the health plan sent a proprietary format to the clearinghouse. HI Health Industry Number (HIN) NF National Association of Insurance Commissioners (NAIC) Code This is the preferred value when identifying the payer. REF-02 127 Additional Payer Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 25 128 PER 1300 Heading Payer Identification Loop PER Payer Business Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send. Example PER CX XXXXX EM XXX EX XXXXX EX XXXX Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 26 128 PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 27 128 PER 1300 Heading Payer Identification Loop PER Payer Technical Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required to report technical contact information for this remittance advice. Example PER BL X TE X TE XXX EM X Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail TE Telephone Recommended UR Uniform Resource Locator (URL) Use only when there is no central telephone number for the payer entity. PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 28 128 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile TE Telephone UR Uniform Resource Locator (URL) PER-06 364 Payer Technical Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile UR Uniform Resource Locator (URL) PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 29 128 1000A Payer Identification Loop end PER 1300 Heading Payer Identification Loop PER Payer WEB Site To identify a person or office to whom administrative communications should be directed Usage notes Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PER IC UR XXXX Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 30 128 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading Payee Identification Loop N1 Payee Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information of the payee. The identifying reference number is provided in N104. Example N1 PE X FI XXXXXXX Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number. XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). This only applies in cases of post payment recovery. See section 1.10.2.16 (Post Payment Recovery) for further information. XX Centers for Medicare and Medicaid Services National Provider Identifier This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate. N1-04 67 Payee Identification Code Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 31 128 This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 32 128 N3 1000 Heading Payee Identification Loop N3 Payee Address To specify the location of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N3 XXXXXX X Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 33 128 N4 1100 Heading Payee Identification Loop N4 Payee City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N4 XXXXXXX XX XXXXXX XXX Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 34 128 REF 1200 Heading Payee Identification Loop REF Payee Additional Identification To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example REF D3 XXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number D3 National Council for Prescription Drug Programs Pharmacy Number PQ Payee Identification TJ Federal Taxpayer's Identification Number This information must be in the N1 segment unless the National Provider ID or the Health Plan Identifier (HPID) or Other Entity Identifier (OEID) was used in N104. For individual providers as payees, use this number to represent the Social Security Number. TJ also represents the Employer Identification Number (EIN). According to the IRS, TIN and EIN can be used interchangeably. REF-02 127 Additional Payee Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 35 128 RDM 1400 Heading Payee Identification Loop RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes Required when BPR01 U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM BM XXX XXXX Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 36 128 1000B Payee Identification Loop end Heading end Contains URL web address | /kaggle/input/edi-db-835-837/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_0 |
specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example REF D3 XXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number D3 National Council for Prescription Drug Programs Pharmacy Number PQ Payee Identification TJ Federal Taxpayer's Identification Number This information must be in the N1 segment unless the National Provider ID or the Health Plan Identifier (HPID) or Other Entity Identifier (OEID) was used in N104. For individual providers as payees, use this number to represent the Social Security Number. TJ also represents the Employer Identification Number (EIN). According to the IRS, TIN and EIN can be used interchangeably. REF-02 127 Additional Payee Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 35 128 RDM 1400 Heading Payee Identification Loop RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes Required when BPR01 U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM BM XXX XXXX Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 36 128 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 37 128 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 0 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 38 128 TS3 0050 Detail Header Number Loop TS3 Provider Summary Information To supply provider-level control information Usage notes TS301 identifies the subsidiary provider. The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000. Required for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity i.e., the corporate office of a hospital chain. If not required by this implementation guide, do not send. Example TS3 XXXXX X 20250130 00000000000 0000000000 0000000 000000000 0000 000 000000000 00 0 00 000000 000000000 Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes When reporting a TS3 segment for professional claims and the claims are not all for the same place of service, report a place of service of 11 (Office) as the default value. When reporting a TS3 segment for pharmaceutical claims and the claims are not all for the same place of service, report a place of service of 99 (Other unlisted facility) as the default value. TS3-03 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year TS303 is the last day of the provider's fiscal year. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 39 128 Use this date for the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known, use December 31st of the current year. TS3-04 380 Total Claim Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity TS304 is the total number of claims. Usage notes This is the total number of claims. TS3-05 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount TS305 is the total of reported charges. Usage notes This is the total reported charges for all claims. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all 782 elements. TS3-13 782 Total MSP Payer Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS313 is the total Medicare Secondary Payer (MSP) primary payer amount. Usage notes See TR3 note 3. TS3-15 782 Total Non-Lab Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS317 is the Health Care Financing Administration Common Procedural Coding System (HCPCS) reported charges. Usage notes See TR3 note 3. TS3-18 782 Total HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 40 128 Monetary amount TS318 is the total Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes See TR3 note 3. TS3-20 782 Total Professional Component Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS320 is the total professional component amount. Usage notes The professional component amount must also be reported in the CAS segment with a Claim Adjustment Reason Code value of 89. See TR3 note 3. TS3-21 782 Total MSP Patient Liability Met Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS321 is the total Medicare Secondary Payer (MSP) patient liability met. Usage notes See TR3 note 3. TS3-22 782 Total Patient Reimbursement Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS322 is the total patient reimbursement. Usage notes See TR3 note 3. TS3-23 380 Total PIP Claim Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS323 is the total periodic interim payment (PIP) number of claims. Usage notes See TR3 note 3. TS3-24 782 Total PIP Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 41 128 See TR3 note 3. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 42 128 TS2 0070 Detail Header Number Loop TS2 Provider Supplemental Summary Information To provide supplemental summary control information by provider fiscal year and bill type Usage notes Required when the value of the Total DRG amount is not zero. If not required by this implementation guide, do not send. This segment provides summary information specific to an iteration of the LX loop (Table 2). Each element represents the total value for the provider bill type combination in this loop 2000 iteration. Required for Medicare Part A. If not required by this implementation guide, do not send. Example TS2 00000 000000000000 00000000000000 00000000000 00 00000000 00000000000 000000000000000 000000000 000000 000000000 0000000000000 0000000000000 0000 0000 00 000000000000 000000 000000000 0000000 000 000000000000 000 Max use 1 Optional TS2-01 782 Total DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS201 is the total diagnosis related group (DRG) amount. Usage notes This includes: operating federal-specific amount, operating hospital-specific amount, operating Indirect Medical Education amount, and operating Disproportionate Share Hospital amount. It does not include any operating outlier amount. See TR3 note 2. TS2-02 782 Total Federal Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS202 is the total federal specific amount. Usage notes See TR3 note 2. TS2-03 782 Total Hospital Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS203 is the total hospital specific amount. Usage notes See TR3 note 2. TS2-04 782 Total Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 43 128 Monetary amount TS204 is the total disproportionate share amount. Usage notes See TR3 note 2. TS2-05 782 Total Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS205 is the total capital amount. Usage notes This includes: capital federal-specfic amount, hospital federal-specfic amount, hold harmless amount, Indirect Medical Education amount, Disproportionate Share Hospital amount, and the exception amount. It does not include any capital outlier amount. See TR3 note 2. TS2-06 782 Total Indirect Medical Education Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS206 is the total indirect medical education amount. Usage notes See TR3 note 2. TS2-07 380 Total Outlier Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS207 is the total number of outlier days. Usage notes See TR3 note 2. TS2-08 782 Total Day Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS208 is the total day outlier amount. Usage notes See TR3 note 2. TS2-09 782 Total Cost Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS209 is the total cost outlier amount. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 44 128 See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS210 is the diagnosis related group (DRG) average length of stay. Usage notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS211 is the total number of discharges. Usage notes This is the discharge count produced by PPS PRICER SOFTWARE. See TR3 note 2. TS2-12 380 Total Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS212 is the total number of cost report days. Usage notes See TR3 note 2. TS2-13 380 Total Covered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS213 is the total number of covered days. Usage notes See TR3 note 2. TS2-14 380 Total Noncovered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS214 is total number of non-covered days. Usage notes See TR3 note 2. TS2-15 782 Total MSP Pass-Through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 45 128 Usage notes See TR3 note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS216 is the average diagnosis-related group (DRG) weight. Usage notes See TR3 note 2. TS2-17 782 Total PPS Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS217 is the total prospective payment system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-18 782 Total PPS Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-19 782 Total PPS DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 46 128 2100 Claim Payment Information Loop Max 1 Required CLP 0100 Detail Header Number Loop Claim Payment Information Loop CLP Claim Payment Information To supply information common to all services of a claim Usage notes For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations. Example CLP XXXX 21 000000000000000 00000000 0000 13 X X X X XXXX 000000000000000 00000000 Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format). CLP-02 1029 Claim Status Code Identifier (ID) Required Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization Usage notes To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code. 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied Usage of this code would apply if the Patient Subscriber is not recognized, and the claim was not forwarded to another payer. 19 Processed as Primary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 20 Processed as Secondary, Forwarded to Additional Payer(s) 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 47 128 When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 22 Reversal of Previous Payment See section 1.10.2.8 for usage information. 23 Not Our Claim, Forwarded to Additional Payer(s) Usage of this code would apply if the patient subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required. 25 Predetermination Pricing Only - No Payment CLP-03 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CLP-04 782 Claim Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 48 128 Code identifying type of claim Usage notes For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2- 005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835. The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer. 12 Preferred Provider Organization (PPO) This code is also used for Blue Cross Blue Shield participating provider arrangements. 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance This code is also used for Blue Cross Blue Shield non-participating provider arrangements. 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical CH Champus DS Disability HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use this code for the Black Lung Program. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 49 128 Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 50 128 CAS 0200 Detail Header Number Loop Claim Payment Information Loop CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note 1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CAS PR XX 00000000000 00000 XXX 0000000000000 000 00000000 XXXX 000000000 00000000000000 XXX 000000 000 000 XX 000000000000 000000000000000 XXX 00000 0 00000000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 51 128 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 52 128 A positive value decreases the covered days, and a negative number increases the covered days. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 53 128 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 54 128 Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 55 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1 QC 1 XX XXXXX XXXXXX XXXXXX MR XXXXXX Variants (all may be used) NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 56 128 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) 34 Social Security Number HN Health Insurance Claim (HIC) Number II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number MR Medicaid Recipient Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 57 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Insured Name To supply the full name of an individual or organizational entity Usage notes In the case of Medicare and Medicaid, the insured patient is always the subscriber and this segment is not used. Required when the original claim reported the insured or subscriber (for example 837 2010BA loop Subscriber Name NM1 Segment) that is different from the patient. If not required by this implementation guide, do not send. This segment contains the same information as reported on the claim (for example 837 2010BA loop Subscriber Name NM1 Segment when the patient was reported in the 2010CA loop Patient Name NM1 Segment). Example NM1 IL 2 XXXX XXXXX XXXXXX XXXXXX II XXXXX Variants (all may be used) NM1 Patient Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 58 128 Individual middle name or initial Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes For example, use when necessary to differentiate between a Junior and Senior under the same contract. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number The code MI is intended to identify that the subscriber's identification number as assigned by the payer will be conveyed in NM109. Payers use different terminology to convey the same number, therefore, the 835 workgroup recommends using MI (Member Identification number) to convey the same categories of numbers as represented in the 837 IGs for the inbound claims. NM1-09 67 Subscriber Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 59 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Patient Insured Name To supply the full name of an individual or organizational entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send. Example NM1 74 2 X XXXXXX X X C XXX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 74 Corrected Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 60 128 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 61 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1 82 1 XXXX XX XXXXXX XXXXXX BS XXXXXX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 62 128 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number FI Federal Taxpayer's Identification Number This is the preferred ID until the National Provider ID is mandated and applicable. For individual providers as payees, use this qualifier to represent the Social Security Number. MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 63 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1 TT 2 XXXXXX NI XXXX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 64 128 PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Crossover Carrier Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 65 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1 PR 2 XXXX NI XXXXXXX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 66 128 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 67 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1 GB 1 XXXXXX XXXXX XXXX XXXXX FI XX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM | /kaggle/input/edi-db-835-837/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_1 |
Insured Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 66 128 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 67 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1 GB 1 XXXXXX XXXXX XXXX XXXXX FI XX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 68 128 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 69 128 MIA 0330 Detail Header Number Loop Claim Payment Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA 00000000000000 00000 0000000000000 0000000000 000 XXX 00000000000000 00000000000000 00000000000 0000 00000000 000000000000 0000000000 000000000 0 000000000000 000 00000 00000 000000000000 00000 0000 000 XXXXX XX XXXXXX XXXXXX 00000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 70 128 MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 71 128 MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 72 128 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 73 128 MOA 0350 Detail Header Number Loop Claim Payment Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when the outpatient institutional claim reimbursement rate is not zero for a Medicare or Medicaid claim. If not required by this implementation guide, do not send. Required for outpatient professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA 00000 0000000000 XXX XXXXXX XXXXX X XXX 00000 000 0000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 74 128 MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 75 128 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REF CE XXXXXX Variants (all may be used) REF Rendering Provider Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number Use this code when conveying the Group Number in REF02. 1W Member Identification Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known. 9A Repriced Claim Reference Number 9C Adjusted Repriced Claim Reference Number 28 Employee Identification Number BB Authorization Number Use this qualifier only when supplying an authorization number that was assigned by the adjudication process and was not provided prior to the services. Do not use this qualifier when reporting the same number as reported in the claim as the prior authorization or pre-authorization number. CE Class of Contract Code See section 1.10.2.15 for information on the use of Class of Contract Code. EA Medical Record Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. G1 Prior Authorization Number Use this qualifier when reporting the number received with the original claim as a pre- authorization number (in the 837 that was at table 2, position 180, REF segment, using the same qualifier of G1). G3 Predetermination of Benefits Identification Number IG Insurance Policy Number Use this code when conveying the Policy Number in REF02. SY Social Security Number 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 76 128 REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 77 128 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Rendering Provider Identification To specify identifying information Usage notes The NM1 segment always contains the primary reference number. Required when additional rendering provider identification numbers not already reported in the Provider NM1 segment for this claim were submitted on the original claim and impacted adjudication. If not required by this implementation guide, do not send. Example REF 1J XX Variants (all may be used) REF Other Claim Related Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 78 128 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 233 20250130 Variants (all may be used) DTM Coverage Expiration Date DTM Claim Received Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 79 128 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM 036 20250130 Variants (all may be used) DTM Statement From or To Date DTM Claim Received Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 80 128 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM 050 20250130 Variants (all may be used) DTM Statement From or To Date DTM Coverage Expiration Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 81 128 PER 0600 Detail Header Number Loop Claim Payment Information Loop PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PER CX X FX XXXXX FX XXXXXX EX XXXXX If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 82 128 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 83 128 AMT 0620 Detail Header Number Loop Claim Payment Information Loop AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT ZO 0000000 Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). D8 Discount Amount Prompt Pay Discount Amount See section 1.10.2.9 for additional information. DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. T Tax T2 Total Claim Before Taxes Used only when tax also applies to the claim. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 84 128 Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 85 128 QTY 0640 Detail Header Number Loop Claim Payment Information Loop QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTY CA 00000 Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual LE Life-time Reserve - Estimated NE Non-Covered - Estimated NR Not Replaced Blood Units OU Outlier Days PS Prescription VS Visits ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 86 128 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78 25 ). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVC AD XXXX XX XX XX XX 00000000000 0000000000 XX XXX 0000000000 ER XXXXX XX XX XX XX X 00000000 Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 87 128 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format N6 National Health Related Item Code in 4-6 Format This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names National Health Related Item Code in 4-6 Format Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. NU National Uniform Billing Committee (NUBC) UB92 Codes UI U.P.C. Consumer Package Code (1-5-5) This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names U.P.C. Consumer Package Code (1-5-5) Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. WK Advanced Billing Concepts (ABC) Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used in transactions covered under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 88 128 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier Max use 1 Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 89 128 To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes WK Advanced Billing Concepts (ABC) Codes This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 90 128 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 91 128 DTM 0800 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 151 20250130 Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 92 128 CAS 0900 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS PR XXXXX 0000000000 00 XXXXX 0000 000 X 000 0 00 XXX 0000000000000 0000000000 XXXX 0000000000 00000 0 XX 0000000000000 000000000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 93 128 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 94 128 A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 95 128 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 96 128 Usage notes See CAS02. CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 97 128 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Service Identification | /kaggle/input/edi-db-835-837/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_2 |
app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 94 128 A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 95 128 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 96 128 Usage notes See CAS02. CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 97 128 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REF 1S X Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF HealthCare Policy Identification Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification BB Authorization Number E9 Attachment Code G1 Prior Authorization Number G3 Predetermination of Benefits Identification Number LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 98 128 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF 6R XXXXX Variants (all may be used) REF Service Identification REF Rendering Provider Information REF HealthCare Policy Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 99 128 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REF HPI XXXXXX Variants (all may be used) REF Service Identification REF Line Item Control Number REF HealthCare Policy Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 100 128 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF 0K XXXXXX Variants (all may be used) REF Service Identification REF Line Item Control Number REF Rendering Provider Information Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 101 128 AMT 1100 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT ZO 0000 Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction T Tax T2 Total Claim Before Taxes Use this monetary amount for the service charge before taxes. This is only used when there is an applicable tax amount on this service. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 102 128 QTY 1200 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTY ZL 00000000 Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 103 128 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQ HE X If Code List Qualifier Code (LQ-01) is present, then Remark Code (LQ-02) is required Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes RX National Council for Prescription Drug Programs Reject Payment Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 104 128 Summary PLB 0100 Summary PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLB XXXXXX 20250130 LE XXXX 000000000000000 XX XX X 000000000 XX XXXXX 000000000000000 XX XXXX 000 0 XX X 00000000 XX XXXX 00000000 If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use 1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 105 128 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AH Origination Fee This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims. AM Applied to Borrower's Account See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this code to identify the loan repayment amount. This is capitation specific. AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 106 128 BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CR Capitation Interest This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CS Adjustment Provide supporting identification information in PLB03-2. CT Capitation Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CV Capital Passthru CW Certified Registered Nurse Anesthetist Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. FC Fund Allocation This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund must be identified in PLB03-2. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 107 128 Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source). C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Use when necessary to assist the receiver in identifying, tracking or reconcilling the adjustment. See sections 1.10.2.10 (Capitation and Related Payments), 1.10.2.5 (Advanced Payments and Reconciliation) and 1.10.2.12 (Balance Forward Processing) for further information. PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PLB04 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. PLB-05 C042 Adjustment Identifier Max use 1 Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 108 128 To provide the category and identifying reference information for an adjustment - PLB05 is the adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB06 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-07 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB07 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-08 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB08 is the adjustment amount. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 109 128 Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-09 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-10 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB10 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-11 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB11 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 110 128 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-12 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB12 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-13 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB13 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 111 128 Summary end SE 0200 Summary SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 000 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 112 128 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 00000 000000000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 113 128 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 00 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 114 128 EDI Samples Example 1: Dollars and Data Sent Separately ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 112233 BPR I 1100 C ACH CCP 01 888999777 DA 24681012 1935665544 01 111333555 DA 144444 20190316 TRN 1 71700666555 1935665544 DTM 405 20190314 N1 PR RUSHMORE LIFE N3 10 SOUTH AVENUET N4 RAPID CITY SD 55111 PER BL JOHN WAYNE TE 8005551212 EX 123 N1 PE ACME MEDICAL CENTER XX 5544667733 REF TJ 777667755 LX 1 CLP 5554555444 1 800 500 300 12 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT AU 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 12 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT AU 1200 SVC HC 93555 1200 600 DTM 472 20190310 CAS PR 1 600 AMT B6 1200 SE 26 112233 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 115 128 Example 2: Multiple Claims Single Check ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1512345678 REF EV XYZ CLEARINGHOUSE N1 PR DENTAL OF ABC N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC XX 9999947036 REF TJ 212121212 LX 1 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 DOE SANDY MI SJD11112 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 119 74 12 119932404007801 11 1 NM1 QC 1 DOE SALLY MI SJD11111 NM1 IL 1 DOE JOHN MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 74 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 12 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 116 128 AMT B6 25 SVC AD D0220 25 0 DTM 472 20190324 CAS PR 3 14 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 0 DTM 472 20190324 CAS PR 3 10 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 1145 14 902 12 119932404007801 11 1 NM1 QC 1 SMITH SAM MI SJD11116 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 14 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D2790 940 0 DTM 472 20190324 CAS PR 3 756 CAS CO 45 184 SVC AD D2950 180 0 DTM 472 20190324 CAS PR 3 146 CAS CO 45 34 CLP 7722337 1 348 16.8 44.2 12 119932404007801 11 1 NM1 QC 1 JONES SAM MI SJD11122 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 28 SVC AD D4342 125 0 DTM 472 20190313 CAS CO 45 125 SVC AD D4381 43 0 DTM 472 20190313 CAS PR 3 33 CAS CO 45 10 SVC AD D2950 180 16.8 DTM 472 20190313 CAS PR 3 11.2 CAS CO 45 152 AMT B6 28 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 JONES SALLY MI SJD11133 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190321 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 117 128 DTM 472 20190321 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190321 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190321 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190321 CAS CO 45 24 AMT B6 49 CLP 7722337 1 179 108 12 119932404007801 11 1 NM1 QC 1 DOE SAM MI SJD99999 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 108 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 129 82 12 119932404007801 11 1 NM1 QC 1 DOE SUE MI SJD88888 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 CLP 7722337 1 221 144 12 119932404007801 11 1 NM1 QC 1 DOE DONNA MI SJD77777 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 144 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0330 92 62 DTM 472 20190324 CAS CO 45 30 AMT B6 62 SVC AD D1120 54 37 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 118 128 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 SE 183 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 119 128 Example 3: Claim Specific Negotiated Discount ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 132 C CHK 20190331 TRN 1 12345 1512345678 REF EV CLEARINGHOUSE N1 PR DELTA DENTAL OF ABC N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC FI 999994703 LX 1 CLP 7722337 1 226 132 12 119932404007801 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 131 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 131 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 131 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 131 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 131 24 AMT B6 49 SE 35 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 120 128 Example 4: Claim Adjustment Reason Code 45 ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 80.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 400 80 MC CLAIMNUMBER 11 1 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004074627 AMT AU 150 SVC HC 99213 150 80 1 DTM 472 20190101 CAS CO 45 70 AMT B6 80 SVC HC 85003 100 0 1 DTM 472 20190101 CAS CO 204 100 SVC HC 36415 150 0 1 DTM 472 20190101 CAS CO 97 150 SE 33 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 121 128 Example 5a: Line Service Tax impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 11.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 36.20 11.06 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 36.20 SVC HC 99214 26.2 3.06 DTM 472 20170109 CAS CO 45 23.2 137 -.06 REF 6R B1 AMT B6 3 SVC HC 36415 10 8 DTM 472 20170109 CAS CO 45 2 REF 6R B2 AMT B6 8 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 122 128 Example 5b: Line Service Bonuses impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 12.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 12 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 12 DTM 472 20170109 CAS CO 45 5 161 -2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 123 128 Example 5c: Line Service Penalty impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 8 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 8 DTM 472 20170109 CAS CO 45 5 B4 2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 124 128 Example 6: Not Covered Not Authorized Inpatient Facility claim days ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8000.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 40000 8000 MC CLAIMNUMBER 11 1 CAS CO 197 2000 1 45 30000 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 232 20190101 DTM 233 20190105 DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004001212 AMT AU 38000 QTY CA 4 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 125 128 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 120.03 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 04777796TLC777122 1 155 120.03 13 8838888212 11 1 NM1 QC 1 MASTERS MARVIN L MI 80444444403 NM1 IL 1 CABLE MABEL MI 80444444403 NM1 74 1 MASTERS MARVIN C 80444444401 NM1 82 1 SHELTON MD BLAKE XX 1666666666 REF 1L 28 REF CE HSOAP-LAOA DTM 232 20191114 DTM 233 20181114 DTM 050 20181119 AMT AU 155 SVC HC 99393 155 120.03 1 DTM 472 20181114 CAS CO 45 34.97 REF LU 11 REF 6R 22261822 AMT B6 120.03 SE 34 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 126 128 Example 8b: Claim submitted with incorrect subscriber name and ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 35.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 02333TLC222222 1 115 35.06 35 13 8333333214 11 1 NM1 QC 1 KEATON ALEX P MI 80000006006 NM1 IL 1 THOMAS JASON MI 80000006006 NM1 74 1 JEROME C 80000006001 NM1 82 1 BLOOD MD RED N XX 1888888886 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191113 DTM 233 20191113 DTM 050 20191119 AMT AU 115 SVC HC 99213 115 35.06 1 DTM 472 20191113 CAS CO 45 44.94 CAS PR 3 35 REF LU 11 REF 6R 22261389 AMT B6 70.06 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 127 128 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 2415.25 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 05444444TLC999999 1 3903 2415.25 13 8777777782 21 1 NM1 QC 1 GONZALES SAMMY MI 80455555502 NM1 IL 1 LAPLANTE FERN MI 80455555502 NM1 74 1 R NM1 82 1 GOOD MD ROBERT B XX 19999999987 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191101 DTM 233 20191101 DTM 050 20191114 AMT AU 3903 AMT F5 150 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF LU 21 REF 6R 22215592 AMT B6 2415.25 SE 35 10060875 GE 1 12345678 IEA | /kaggle/input/edi-db-835-837/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_3 |
PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 126 128 Example 8b: Claim submitted with incorrect subscriber name and ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 35.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 02333TLC222222 1 115 35.06 35 13 8333333214 11 1 NM1 QC 1 KEATON ALEX P MI 80000006006 NM1 IL 1 THOMAS JASON MI 80000006006 NM1 74 1 JEROME C 80000006001 NM1 82 1 BLOOD MD RED N XX 1888888886 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191113 DTM 233 20191113 DTM 050 20191119 AMT AU 115 SVC HC 99213 115 35.06 1 DTM 472 20191113 CAS CO 45 44.94 CAS PR 3 35 REF LU 11 REF 6R 22261389 AMT B6 70.06 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 127 128 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 2415.25 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 05444444TLC999999 1 3903 2415.25 13 8777777782 21 1 NM1 QC 1 GONZALES SAMMY MI 80455555502 NM1 IL 1 LAPLANTE FERN MI 80455555502 NM1 74 1 R NM1 82 1 GOOD MD ROBERT B XX 19999999987 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191101 DTM 233 20191101 DTM 050 20191114 AMT AU 3903 AMT F5 150 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF LU 21 REF 6R 22215592 AMT B6 2415.25 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 128 128 | /kaggle/input/edi-db-835-837/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_4 |
Stedi maintains this guide based on public documentation from Health Partner Plans. Contact Health Partner Plans for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment Advice (X221A1) X12 Release 5010 Revised February 22, 2024 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution. Delimiters Segment Element Component Repetition View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view health-partner-plans health-care-claim- paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K POWERED BY Build EDI implementation guides at stedi.com 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 1 82 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0100 Transaction Set Header Max use 1 Required BPR 0200 Financial Information Max use 1 Required TRN 0400 Reassociation Trace Number Max use 1 Required REF 0600 Receiver Identification Max use 1 Optional Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required PER 1300 Payers Claim Office Max use 1 Optional PER 1300 Technical Department Max use 1 Required PER 1300 Uniform Resource Locator (URL) Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Federal Taxpayer's Identification Number Max use 1 Optional REF 1200 Payee Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional Detail Header Number Loop LX 0030 Header Number Max use 1 Required Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 2 82 CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Other Insured Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 3 82 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250130 0825 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 4 82 Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 5 82 Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 6 82 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HP XXXX XX 20250130 1226 000 X 005010X221A1 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 7 82 X Accredited Standards Committee X12 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X221A1 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 8 82 Heading ST 0100 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 835 0001 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 9 82 BPR 0200 Heading BPR Financial Information To indicate the beginning of a Payment Order Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and or information from payer to payee to occur Usage notes Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPR I 0000000000000 C CHK 20250130 Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. BPR-02 782 Total Actual Provider Payment Amount Decimal number (R) Required Min 1 Max 15 Monetary amount BPR02 specifies the payment amount. Usage notes Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). BPR-03 478 Credit or Debit Flag Code Identifier (ID) Required Code indicating whether amount is a credit or debit C Credit Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment. BPR-04 591 Payment Method Code Identifier (ID) Required Code identifying the method for the movement of payment instructions 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 10 82 CHK Check Use this code to indicate that a check has been issued for payment. BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). Usage notes Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is NON', enter the date of the 835. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 11 82 TRN 0400 Heading TRN Reassociation Trace Number To uniquely identify a transaction to an application Usage notes This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. Example TRN 1 XX XXXXXXXXXX Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN02 provides unique identification for the transaction. Usage notes This number must be unique within the sender receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non- payment 835, this must be a unique remittance advice identification number. See 1.10.2.3, Reassociation of Dollars and Data, for additional information. Check Number TRN-03 509 Payer Identifier Min 10 Max 10 String (AN) Required A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. TRN03 identifies an organization. Usage notes This must be a 1 followed by the payer's EIN (or TIN). 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 12 82 REF 0600 Heading REF Receiver Identification To specify identifying information Usage notes This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee. Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example REF EV XX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Receiver Identification Number 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 13 82 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading Payer Identification Loop N1 Payer Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information for the payer. The payer's secondary identifying reference number is provided in N104, if necessary. Example N1 PR Health Partners of Philadelphia Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name String (AN) Required Free-form name Health Partners of Philadelphia 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 14 82 N3 1000 Heading Payer Identification Loop N3 Payer Address To specify the location of the named party Example N3 901 Market St Suite 500 Max use 1 Required N3-01 166 Payer Address Line String (AN) Required Address information 901 Market St N3-02 166 Payer Address Line String (AN) Optional Address information Suite 500 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 15 82 N4 1100 Heading Payer Identification Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4 Philadelphia PA 19107 XXX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Payer City Name String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Philadelphia N4-02 156 Payer State Code Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. PA N4-03 116 Payer Postal Zone or ZIP Code Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) 19107 N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 16 82 Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 17 82 PER 1300 Heading Payer Identification Loop PER Payers Claim Office To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send. Example PER CX Claim Department TE 2159914350 TE XXX EX X X Variants (all may be used) PER Technical Department PER Uniform Resource Locator (URL) If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). Claim Department PER-03 365 Communication Number Qualifier Identifier (ID) Optional 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 18 82 Code identifying the type of communication number TE Telephone PER-04 364 Payer Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable 2159914350 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 19 82 PER 1300 Heading Payer Identification Loop PER Technical Department To identify a person or office to whom administrative communications should be directed Usage notes Required to report technical contact information for this remittance advice. Example PER BL EDI Support TE 2159914290 EM EDI HEALTHPAR T.COM FX XXXX Variants (all may be used) PER Payers Claim Office PER Uniform Resource Locator (URL) If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). EDI Support PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number TE Telephone Recommended PER-04 364 Payer Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 20 82 2159914290 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail PER-06 364 Payer Technical Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable EDI HEALTHPART.COM PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile UR Uniform Resource Locator (URL) PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 21 82 1000A Payer Identification Loop end PER 1300 Heading Payer Identification Loop PER Uniform Resource Locator (URL) To identify a person or office to whom administrative communications should be directed Usage notes Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PER IC UR www.healthpart.com Variants (all may be used) PER Payers Claim Office PER Technical Department Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. www.healthpart.com 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 22 82 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading Payee Identification Loop N1 Payee Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information of the payee. The identifying reference number is provided in N104. Example N1 PE XXX XX XXXX Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number. XX Centers for Medicare and Medicaid Services National Provider Identifier This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate. N1-04 67 Payee Identification Code Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 23 82 This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 24 82 N3 1000 Heading Payee Identification Loop N3 Payee Address To specify the location of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Situational (when needed to inform Receiver of Payee Address) Example N3 XXX XXXXXX Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information Usage notes Payee Address Information provided to Health Partners N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information Usage notes Payee Address Information, if second line needed 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 25 82 N4 1100 Heading Payee Identification Loop N4 Payee City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Situational (when needed to inform Receiver) Example N4 XXXXXX XX XXXXXXXX XXX Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Usage notes Payee City Name provided N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. Usage notes Payee State Name provided N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes Payee Zip Code provided N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 26 82 Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 27 82 REF 1200 Heading Payee Identification Loop REF Federal Taxpayer's Identification Number To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Situational (When additional identification is needed) Example REF TJ XXXXXX Variants (all may be used) REF Payee Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification TJ Federal Taxpayer's Identification Number REF-02 127 Additional Payee Identifier Min 1 Max 30 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Federal Taxpayer Identification Number 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 28 82 REF 1200 Heading Payee Identification Loop REF Payee Identification To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Situational (When additional identification is needed) Example REF PQ X Variants (all may be used) REF Federal Taxpayer's Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PQ Payee Identification REF-02 127 Additional Payee Identifier Min 1 Max 30 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Health Partners Legacy Number 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 29 82 RDM 1400 Heading Payee Identification Loop RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes Required when BPR01 U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM BM XXX XXXX Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 30 82 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 31 82 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 00000 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 32 82 2100 Claim Payment Information Loop Max 1 Required CLP 0100 Detail Header Number Loop Claim Payment Information Loop CLP Claim Payment Information To supply information common to all services of a claim Usage notes For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations. Example CLP XX 2 0000000 000000000 000 HM XXX XX X XX 00 0 Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format). CLP-02 1029 Claim Status Code Identifier (ID) Required Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization Usage notes To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code. Claim Status. See page 124 of HIPAA TR3 for valid codes 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 33 82 Usage of this code would apply if the Patient Subscriber is not recognized, and the claim was not forwarded to another payer. 19 Processed as Primary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 20 Processed as Secondary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 22 Reversal of Previous Payment See section 1.10.2.8 for usage information. 23 Not Our Claim, Forwarded to Additional Payer(s) Usage of this code would apply if the patient subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required. 25 Predetermination Pricing Only - No Payment CLP-03 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CLP-04 782 Claim Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 34 82 Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim Usage notes For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2- 005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835. The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer. HM Health Maintenance Organization CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 35 82 when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems Usage notes Code Source 229. Institutional claims only. CLP-12 380 Diagnosis Related Group (DRG) Weight Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 36 82 CAS 0200 Detail Header Number Loop Claim Payment Information Loop CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note 1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CAS PI XXX 00000000000000 00000000 Max use 99 Optional CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 37 82 Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. Code Source 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. Claim Level Adjustment Amount CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. A positive value decreases the covered days, and a negative number increases the covered days. Provided only when unit quantity is being adjusted 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 38 82 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Insured To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1 | /kaggle/input/edi-db-835-837/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_0 |
not send. Example CAS PI XXX 00000000000000 00000000 Max use 99 Optional CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 37 82 Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. Code Source 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. Claim Level Adjustment Amount CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. A positive value decreases the covered days, and a negative number increases the covered days. Provided only when unit quantity is being adjusted 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 38 82 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Insured To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1 GB 2 X XX XXXX XXXXXX FI XXXXX Variants (all may be used) NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 39 82 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 40 82 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1 QC 1 XX XXXXXX XX MI XXXXX Variants (all may be used) NM1 Other Insured NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 41 82 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) MI Member Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 42 82 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1 82 1 XX X XX XXX Variants (all may be used) NM1 Other Insured NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Name Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Name First Min 1 Max 35 String (AN) Optional Individual first name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 43 82 XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes National Provider Identifier Number Provided 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 44 82 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM 050 20250130 Variants (all may be used) DTM Coverage Expiration Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 45 82 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Situational (Required due to expiration of coverage) Example DTM 036 20250130 Variants (all may be used) DTM Claim Received Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 46 82 AMT 0620 Detail Header Number Loop Claim Payment Information Loop AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT D8 000 Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D8 Discount Amount Prompt Pay Discount Amount See section 1.10.2.9 for additional information. I Interest See section 1.10.2.9 for additional information. T Tax AMT-02 782 Claim Supplemental Information Amount Decimal number (R) Required Min 1 Max 15 Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 47 82 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78 25 ). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVC NU XXX XX XX XX XX 00000000 00000000000000 0 00 ER X 000000000 Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. See HIPAA 835 Technical Report Type 3, pg. 187-188 for supported codes AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 48 82 HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format N6 National Health Related Item Code in 4-6 Format This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names National Health Related Item Code in 4-6 Format Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. NU National Uniform Billing Committee (NUBC) UB92 Codes UI U.P.C. Consumer Package Code (1-5-5) This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names U.P.C. Consumer Package Code (1-5-5) Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. WK Advanced Billing Concepts (ABC) Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used in transactions covered under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 49 82 C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Max use 1 Optional 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 50 82 Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. Provided if procedure code in SVC01 is different from procedure code submitted; see pg. 191 of the HIPAA Technical Report Type 3 AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes WK Advanced Billing Concepts (ABC) Codes This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. Usage notes 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 51 82 Only provided when paid unit is different from submitted units 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 52 82 DTM 0800 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 151 20250130 Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 53 82 CAS 0900 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Situational (to account for difference in amount paid for this service) Example CAS CO XXXX 0000000 00000000000000 Max use 99 Optional CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 54 82 CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. Code Source 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 55 82 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF 6R XX Variants (all may be used) REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 56 82 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REF TJ XXXX Variants (all may be used) REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 57 82 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REF APC XX Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification BB Authorization Number E9 Attachment Code G1 Prior Authorization Number G3 Predetermination of Benefits Identification Number LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 58 82 AMT 1100 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT ZK 00000000000 Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction T Tax T2 Total Claim Before Taxes Use this monetary amount for the service charge before taxes. This is only used when there is an applicable tax amount on this service. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. Corresponding Amount (Service Line Allowed Amount) 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 59 82 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQ HE XXX Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 60 82 Summary PLB 0100 Summary PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLB XXXXX 20250130 PI 00000 Max use 1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year PLB02 is the last day of the provider's fiscal year. Usage notes 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 61 82 This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment Usage notes Refer to HIPAA Technical Report Type pg. 219-222 for supported Code Values 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AH Origination Fee This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims. AM Applied to Borrower's Account See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this code to identify the loan repayment amount. This is capitation specific. AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 62 82 adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CR Capitation Interest This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CS Adjustment Provide supporting identification information in PLB03-2. CT Capitation Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CV Capital Passthru CW Certified Registered Nurse Anesthetist Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. FC Fund Allocation This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund must be identified in PLB03-2. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 63 82 LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source). PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PLB04 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 64 82 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 65 82 Summary end SE 0200 Summary SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 0000 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 66 82 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 000000 0000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 67 82 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 0 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 68 82 EDI Samples Example 1: Dollars and Data Sent Separately ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 112233 BPR I 1100 C CHK 20190316 TRN 1 71700666555 1935665544 N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM N1 PE ACME MEDICAL CENTER XX 5544667733 REF TJ 777667755 LX 1 CLP 5554555444 1 800 500 300 HM 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT D8 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 HM 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT D8 1200 SVC HC 93555 1200 600 DTM 472 20190310 CAS PR 1 600 AMT B6 1200 SE 25 112233 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 69 82 Example 2: Multiple Claims Single Check ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1512345678 REF EV XYZ CLEARINGHOUSE N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER BL EDI Support TE 2159914290 N1 PE BAN DDS LLC XX 9999947036 REF TJ 212121212 LX 1 CLP 7722337 1 226 132 HM 119932404007801 11 1 NM1 QC 1 DOE SANDY MI SJD11112 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 119 74 HM 119932404007801 11 1 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 74 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 HM 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 132 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 70 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 | /kaggle/input/edi-db-835-837/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_1 |
Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 68 82 EDI Samples Example 1: Dollars and Data Sent Separately ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 112233 BPR I 1100 C CHK 20190316 TRN 1 71700666555 1935665544 N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM N1 PE ACME MEDICAL CENTER XX 5544667733 REF TJ 777667755 LX 1 CLP 5554555444 1 800 500 300 HM 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT D8 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 HM 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT D8 1200 SVC HC 93555 1200 600 DTM 472 20190310 CAS PR 1 600 AMT B6 1200 SE 25 112233 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 69 82 Example 2: Multiple Claims Single Check ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1512345678 REF EV XYZ CLEARINGHOUSE N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER BL EDI Support TE 2159914290 N1 PE BAN DDS LLC XX 9999947036 REF TJ 212121212 LX 1 CLP 7722337 1 226 132 HM 119932404007801 11 1 NM1 QC 1 DOE SANDY MI SJD11112 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 119 74 HM 119932404007801 11 1 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 74 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 HM 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 132 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 70 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 0 DTM 472 20190324 CAS PR 3 14 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 0 DTM 472 20190324 CAS PR 3 10 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 1145 14 902 HM 119932404007801 11 1 NM1 QC 1 SMITH SAM MI SJD11116 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 14 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D2790 940 0 DTM 472 20190324 CAS PR 3 756 CAS CO 45 184 SVC AD D2950 180 0 DTM 472 20190324 CAS PR 3 146 CAS CO 45 34 CLP 7722337 1 348 16.8 44.2 HM 119932404007801 11 1 NM1 QC 1 JONES SAM MI SJD11122 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 28 SVC AD D4342 125 0 DTM 472 20190313 CAS CO 45 125 SVC AD D4381 43 0 DTM 472 20190313 CAS PR 3 33 CAS CO 45 10 SVC AD D2950 180 16.8 DTM 472 20190313 CAS PR 3 11.2 CAS CO 45 152 AMT B6 28 CLP 7722337 1 226 132 HM 119932404007801 11 1 NM1 QC 1 JONES SALLY MI SJD11133 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 71 82 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 132 SVC AD D0120 46 25 DTM 472 20190321 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190321 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190321 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190321 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190321 CAS CO 45 24 AMT B6 49 CLP 7722337 1 179 108 HM 119932404007801 11 1 NM1 QC 1 DOE SAM MI SJD99999 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 108 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 129 82 HM 119932404007801 11 1 NM1 QC 1 DOE SUE MI SJD88888 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 CLP 7722337 1 221 144 HM 119932404007801 11 1 NM1 QC 1 DOE DONNA MI SJD77777 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 72 82 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 144 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0330 92 62 DTM 472 20190324 CAS CO 45 30 AMT B6 62 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 SE 182 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 73 82 Example 3: Claim Specific Negotiated Discount ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 132 C CHK 20190331 TRN 1 12345 1512345678 REF EV CLEARINGHOUSE N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER BL EDI Support TE 2159914290 N1 PE BAN DDS LLC FI 999994703 LX 1 CLP 7722337 1 226 132 HM 119932404007801 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 131 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 131 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 131 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 131 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 131 24 AMT B6 49 SE 35 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 74 82 Example 4: Claim Adjustment Reason Code 45 ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 80.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 400 80 HM CLAIMNUMBER 11 1 NM1 QC 1 DOE JOHN N MI ABC123456789 DTM 050 20190209 AMT D8 150 SVC HC 99213 150 80 1 DTM 472 20190101 CAS CO 45 70 AMT B6 80 SVC HC 85003 100 0 1 DTM 472 20190101 CAS CO 204 100 SVC HC 36415 150 0 1 DTM 472 20190101 CAS CO 97 150 SE 30 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 75 82 Example 5a: Line Service Tax impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 11.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 36.20 11.06 HM CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 DTM 050 20170113 AMT D8 36.20 SVC HC 99214 26.2 3.06 DTM 472 20170109 CAS CO 45 23.2 REF 6R B1 AMT B6 3 SVC HC 36415 10 8 DTM 472 20170109 CAS CO 45 2 REF 6R B2 AMT B6 8 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 76 82 Example 5b: Line Service Bonuses impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 12.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 12 10 HM CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 DTM 050 20170113 AMT D8 25 SVC HC 99214 25 12 DTM 472 20170109 CAS CO 45 5 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 77 82 Example 5c: Line Service Penalty impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 8 10 HM CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 DTM 050 20170113 AMT D8 25 SVC HC 99214 25 8 DTM 472 20170109 CAS CO 45 5 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 78 82 Example 6: Not Covered Not Authorized Inpatient Facility claim days ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8000.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 40000 8000 HM CLAIMNUMBER 11 1 CAS CO 197 2000 1 NM1 QC 1 DOE JOHN N MI ABC123456789 DTM 050 20190209 AMT D8 38000 SE 21 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 79 82 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 120.03 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 04777796TLC777122 1 155 120.03 HM 8838888212 11 1 NM1 QC 1 MASTERS MARVIN L MI 80444444403 NM1 82 1 SHELTON MD BLAKE XX 1666666666 DTM 050 20181119 AMT D8 155 SVC HC 99393 155 120.03 1 DTM 472 20181114 CAS CO 45 34.97 REF LU 11 REF 6R 22261822 AMT B6 120.03 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 80 82 Example 8b: Claim submitted with incorrect subscriber name and ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 35.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 02333TLC222222 1 115 35.06 35 HM 8333333214 11 1 NM1 QC 1 KEATON ALEX P MI 80000006006 NM1 82 1 BLOOD MD RED N XX 1888888886 DTM 050 20191119 AMT D8 115 SVC HC 99213 115 35.06 1 DTM 472 20191113 CAS CO 45 44.94 CAS PR 3 35 REF LU 11 REF 6R 22261389 AMT B6 70.06 SE 28 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 81 82 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 2415.25 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 05444444TLC999999 1 3903 2415.25 HM 8777777782 21 1 NM1 QC 1 GONZALES SAMMY MI 80455555502 NM1 82 1 GOOD MD ROBERT B XX 19999999987 DTM 050 20191114 AMT D8 3903 AMT I 150 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF LU 21 REF 6R 22215592 AMT B6 2415.25 SE 28 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 82 82 | /kaggle/input/edi-db-835-837/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_2 |
HIPAA Transaction Standard Companion Guide 835 Health Care Claim Payment Advice Refers to the Implementation Guides Based on X12 version 005010 Errata Companion Guide Version Number: 1.1 February 2024 Disclaimer Statement The Health Insurance Portability and Accountability Act (HIPAA), sections 160 and 162, require that health care providers, health plans, and health care clearing houses comply with the EDI standards for health care. The HIPAA implementation specifications for ASC X12N standards may be obtained through the Washington Publishing Company on the Internet at http: www.wpcedi.com. The purpose of this companion guide is solely to supplement the HIPAA ASC X12N standards, to provide clarification to the ASC X12N standards, and should not be interpreted as a contract, amendment to a contract or an addendum to a contract. In any instance where this companion guide differs from the HIPAA ASC X12N Implementation Guides, the HIPAA ASC X12N standards shall govern. Substantial effort has been taken to minimize errors; however, SummaCare, Inc, its agents, employees, directors and shareholders shall not be liable or responsible for any errors, omissions or expenses resulting from the use of the information in this document Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 Table of Contents 1 Introduction................................................................................................................................................4 1.1 Overview 2 Eligibility 3 Data Exchange Frequency 4 Electronic Funds Transfer (EFT) 5 Claim Remittance Processing...................................................................................................................5 5.1 Interchange Control Structure 5.2 Sorting order of data within the 835 file 5.3 Claims returned within the 835 6 Claims Batch Matching 7 Bundling Unbundling 8 Identification Codes and Numbers............................................................................................................6 8.1 Provider Identifiers 8.2 Subscriber Identifiers 8.3 Payer Claim Control Number 8.4 Adjustment Group and Reason Codes 8.5 Remarks Codes 9 Special Handling.......................................................................................................................................6 9.1 Federal Surprise Act (NSA) 10 Inquiries...............................................................................................................................................7-10 11 835 Data Element Table 11.1 835 Health Care Claim Payment Advice Header 11.2 835 Health Care Claim Payment Advice Detail 11.3 835 Health Care Claim Payment Advice Summary 12 835 Claim Payment Advice Transaction Sample..............................................................................11-12 12.1 Claim Payment Advice Scenario 12.2 Claim Payment Advice Example ANSI X 12 13 Version History.......................................................................................................................................12 14 Frequently Asked Questions FAQ.......................................................................................................13 Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 1 Introduction 1.1 Overview This Companion Guide identifies unique information processing or adjudication needs specific to SummaCare, Inc in its implementation of the 835 Health Care Claim Payment Advice and should be used in conjunction with the HIPAA 835 Implementation Guide. Throughout this document, SummaCare represents SummaCare, Inc. This companion guide contains three categories of information: General information applicable to the processing of claims and business edits performed by SummaCare. The transaction table outlining specific requests for data format or content within the transaction, or describing SummaCare handling of specific data types. Additional information containing a sample scenario and frequently asked questions (FAQ). All claims (paper and electronic) will be reported on the 835, if a provider submitter chooses to receive the 835. While SummaCare accepts all ASCX12 compliant transactions, the HIPAA Implementation Guides allow for some discretion in applying the regulations to existing business practices. Understanding SummaCare business practices may expedite claims processing for trading partners as they exchange EDI transactions with SummaCare. 2 Eligibility In order to receive an 835 Health Care Claim Payment Advice, submitters of health care claims can complete the following: Complete and submit a Trading Partner Agreement to SummaCare or enter into a contractual agreement with a SummaCare contracted Trading Partner. Complete the SummaCare 835 Registration Form. Complete testing requirements with SummaCare. 3 Data Exchange Frequency New files may be available each business day by noon eastern standard time. 4 Electronic Funds Transfer (EFT) The SummaCare 835 Transaction is for notification only and does not include Electronic Fund Transfer (EFT) to financial institutions. Providers who would like to Implement EFT can log into their Plan Central account and register or complete the EFT form on SummaCare s website at http: www.summacare.com Provider ResourcesAndSelfServices EDIRegistration.aspx, complete and mail in the EFT Registration Form to the address on the form. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 5 Claim Remittance Processing 5.1 Interchange Control Structure 835 transactions are generated one file per Trading Partner during each scheduled payables process. The envelope structure is as follows for each individual check processed within a file. If a Trading Partner receives more than one check payment within the 835 then there will be multiple iterations of the structure below within the file. ISA - Interchange Control Header GS - Functional Group header ST - Transaction Set Header Detail Segments (Please see the Implementation Guide for All possible detail segments) SE - Transaction Set Trailer GE - Functional Group Trailer IEA - Interchange Control Trailer 5.2 Sorting order of data within the 835 file Within the 835 transaction file the Interchange Control Structure(s) are ordered by check number in ascending order. The check number is located in the TRN02 segment. For each check within the 835 transaction the claims are ordered by claim number in ascending order. The claim number is located in the CLP07 segment. 5.3 Claims returned within the 835 Notes that are important to claims processing are as follows: 835 Transactions are only generated for claims that have a "paid" or "denied" status. Claims still in the adjudication process or returned with an error messages do not receive an 835 response. If a provider submits claims on paper and EDI claims, SummaCare will generate a format compliant 835 Health Care Claim Payment Advice transaction with required elements. However, the content of the resulting 835 will not be as complete as an 835 resulting from an electronic 837 Claim transaction. SummaCare will turn off the paper Explanation of Payments (EOP) once a provider starts receiving the 835 transaction. The provider may access Plan Central to review a Portable Document Format (PDF) image of their EOP. To register and access this service please visit http: www.summacare.com Provider ResourcesAndSelfServices.aspx 6 Claims Batch Matching Please note that there is not batch matching between 837 Health Care Claims and 835 Health Care Claim Payment Advice. 7 Bundling Unbundling As claims are processed, professional services reflected by procedure codes are bundled or unbundled utilizing SummaCare business processes. Procedure codes are returned for professional health care claims as processed reflecting SummaCare payment record. This does not necessarily reflect procedure codes submitted. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 8 Identification Codes and Numbers SummaCare uses the standard medical and non-medical code sets indicated in Appendix C of the 835 Payment Advice Remittance Implementation Guide. 8.1 Provider Identifiers SummaCare accepts the National Provider Identifier and Tax Identification numbers for provider's mandated by the state to obtain one. For exempt providers we will accept the Tax Identification number. 8.2 Subscriber Identifiers The Subscriber Identifier returned on the 835 Claim Payment Advice is the membership identifier that appears within the SummaCare system which could be different than what was submitted on the 837 Health Care Claims transaction. If this identifier differs from that which was submitted, assume the returned identifier on the 835 transactions is correct. 8.3 Payer Claim Control Number The Payer Claim Control Number (Payer Patient Control Number in the 2100 loop, CLP07) is the 12-digit claim number assigned to each claim by SummaCare. Receivers of the 835 Health Care Claim Payment Advice should use their Patient Control Number (Patient Control Number CLP01) and dates of service, in conjunction with the CLP07 value to match claims with remittances. If the Patient Control Number is submitted on paper claims, then this number will be returned on the 835 Health Care Claim Payment Advice. If there is no Patient Control Number on the paper claim, then the value of "0" will be returned. 8.4 Adjustment Group and Reason Codes For claim adjustment reason code use code source 139 and for Health Care Remark Codes, use source code 411. 8.5 Remarks Codes We will be returning the HIPAA Standard Remarks Codes (Loop2110, segment LQ02) along with our current Explanation Codes (Loop 2110, segment REF02). 9 Special Handling In the event that we are unable to produce an 835 Health Care Claim Payment Advice electronically, SummaCare will generate a paper Explanation of Payment (EOP). 9.1 Federal No Surprises Act (NSA) SummaCare complies with both federal and state NSA requirements. When RARC code N862 is found in the LQ segment, please reference additional information regarding federal NSA on SummaCare.com using the following link: https: www.summacare.com no-surprises-act 10 Inquiries For inquiries concerning the EFT (Electronic Funds Transfer) please contact our Finance Department at (330) 996-8461. All other inquiries should contact: SummaCare Provider Support Services at (330) 996-8400 or 1-800-996-8401 or by email: contactproviderservices summacare.com. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 11 835 Data Element Table 11.1 835 Health Care Claim Payment Advice Header The 835 Transaction Set Header contains general information about the claim payment, such as Payee,Amount,Payer,Payment method, and Trace Number. The following table explains the header segments and data elements that require specific information for SummaCare processing. Envelope Section Label Segment Description Value Options for SummaCare Description Comments Financial Information BPR01 Transaction Handling Code I, C, D I - Remittance information only C-Payment Accompanies Remittance Advice D- Make payment only Financial Information BPR03 Credit Debit Flag Code C C - Credit Financial Information BPR04 Payment Method Code ACH, CHK ACH - Automated Clearing House CHK - Check Financial Information BPR05 Payment Format Code CCP CCP - Cash Concentration Disbursement plus Addenda Financial Information BPR06 DFI ID Number Qualifier 01 01 - ABA Transit Routing Number Including Check Digit (9 digits) Financial Information BPR07 Sender DFI ID Number Sender DFI ID Represents Summa Insurance Company Summa Health Network SummaCare Bank Number Financial Information BPR09 Sender Bank Account Number Sender Bank Account Number Represents Summa Insurance Company Summa Health Network SummaCare Bank Account Number Financial Information BPR10 Originating Company Identifier Same value as the TRN03 This will be sent when the BPR04 is present Financial Information BPR12 DFI ID Number Qualifier 01 01 - ABA Transit Routing Number Including Check Digit (9 digits) Financial Information BPR13 Receiver DFI ID Number Receiver DFI ID Represents Receiver Provider's Bank Number Financial Information BPR15 Receiver Bank Account Number Receiver Bank Account Number Represents Receiver Provider's Bank Account Number Financial Information BPR16 Check Issue or EFT Effective Date Date Represent the Check Issue Date or EFT Effective Date Re-association Trace Number TRN02 Check or EFT Trace Number Check Number, Advice Number Check Number- If the Provider Receives a Paper Check Advice Number - If the Provider Receives an EFT Re-association Trace Number TRN03 Payer Identifier 95202 SummaCare Payer Identification Number Receiver Identification REF01 Reference Identification Qualifier EV EV - Receiver ID Number Receiver Identification REF02 Receiver Identifier Receiver's EDI Sender ID Number Represents the Receiver's EDI Sender ID Number Assigned by SUMMACARE Table 1 - 835 Claim Payment Advice - Header Transaction Set Header LOOP ID - 1000B Payee Identification Payee Identification N103 Identification Code Qualifier XX or FI XX - Centers for Medicare and Medicaid Services National Provider Identifier(NPI) FI - Federal Tax Identification (This should only be sent for Exempt Providers) Payee Identification N104 Payee Identification Code Provider s NPI Number or Tax ID number Represents the Provider's NPI number or Federal Tax ID number. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 11.2 835 Health Care Claim Payment Advice Detail The 835 Payment Advice detail level contains the explanations of benefits and charges paid, reduced, or denied related to the adjudicated claims and services. The Claim Payment and Service Patient Information are contained in Loops 2100 and 2110 in the following table. The table also explains the situational segments and data elements that require specific information for SummaCare processing. Table 2 - 835 Claim Payment Advice - Detail LOOP ID - 2100 Claims Payment Information Envelope Section Label Segment Description Value Options for SummaCare Description Comments Claim Payment Information CLP01 Patient Control Number Patient Control Number (UB04) Patient Account Number (HCFA) For Electronic Claims, this field will contain the value received in CLM01 on the inbound 837. For Paper Claims, this field will contain the value received in block 26 on the HCFA and block 3a on the UB04 claim forms. If the patient control number was not present on the inbound claim, a zero will appear here. Claim Payment Information CLP07 Payer Claim Control Number SUMMACARE Claim Number Represents the claim number assigned by SUMMACARE Patient Name NM108 Identification Code Qualifier MI MI - Member Identification Number Patient Name NM109 Patient Identifier SummaCare member number plus 2 digit suffix Represents the Member Identification Number Insured Name NM108 Identification Code Qualifier MI This segment is only used when the patient is not the subscriber MI - Member Identification Number Insured Name NM109 Patient Identifier SummaCare Subscriber's number This segment is only used when the patient is not the subscriber Represents the Member Identification Number Service Provider Name NM108 Identification Code Qualifier XX or FI XX -Centers for Medicare and Medicaid Services National Provider Identifier(NPI) FI - Federal Tax Identification(This should only be sent for Exempt Providers) Service Provider Name NM109 Identification Code Provider s NPI Number or Tax ID Number Represents the Provider ID Claim Date DTM01 Date Time Qualifier One of the following values: 232,233 232- Claim Statement Period Start 233 - Claim statement Period End Claim Date DTM02 Date Date specified by the code used in DTM01 Date specified by the code used in DTM01 LOOP ID - 2110 Service Payment Information Service Payment Information SVC01-1 Product or Service ID Qualifier One of the following values: AD HC NU AD - American Dental Association Codes HC - Health Care Financing Administration Common Procedural Coding System Codes (HCPCS) NU - National Uniform Billing Committee Codes (NUBC) UB92 codes Service Payment Information SVC06-2 Product Service ID Procedure Code This element will be used if the submitted procedure code was bundled.The new bundled procedure code will be placed here. Service Date DTM01 Date Time Qualifier One of the following values: 150, 151 or 472 150 - Service Period Start 151 - Service Period End 472 - Service Service Date DTM02 Date Service date Service date Service Identification REF01 Reference Identification Qualifier E9 E9 - Attachment Code Service Identification REF02 Reference Identification EX codes attached to the Service Line without the description of the EX Code. This represents SummaCare s internal explanation code that is shown on the paper EOP. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 11.3 835 Health Care Claim Payment Advice Summary The summary level contains the Provider Level Adjustment Segment and provides information related to adjustments to the payment amount not specific to the Detail level. The adjustments can either increase or decrease the actual payment. The following table also explains the situational segments and data elements that require specific information for SummaCare Processing. Table 3 - 835 Claim Payment Advice - Summary Envelope Section Label Segment Description Value Options for SummaCare Description Comments Provider Level Adjustment PLB01 Provider Identifier Payee ID Number Represents the Payee NPI. If the Payee is not required under the Mandate to acquire an NPI Number this will represent the ID Number assigned by SUMMACARE. Page of 12 835 Claim Payment Advice Transaction Sample 12.1 Claim Payment Advice Scenario On September 2, 2023, Jonathan Doe was experiencing pain in his leg and ankle. He was taken to Healthy Hospital for an x-ray of his foot and ankle. The hospital submitted the bill to their clearinghouse. On September 18, 2023, the clearinghouse transmitted a claim to SummaCare in the 837I file format, for 583.70. On September 25, 2023, SummaCare issued a check for 171.55 to Healthy Hospital for their services. Claim Information Payment: 175.11 Check Date: 9 25 2023 Facility Billed Amount: 583.70 Check: 97CF0000000411 Facility TIN: 207661234 Claim Production run date: 9 18 2023 Payer Name: SummaCare Payer Address: 1200 E. Market Street Suite 400 Akron, OH 44305-4018 Facility: Healthy Hospital Facility National Provider Identification (NPI) Number: 1234567890 Patient: Jonathan Doe Patient ID: 98765432103 Patient Account: 330866922 Date of Service: 9 2 2023 CPT Codes: 73610, 73630 Revenue Codes: 320 Adjustment: 408.59 due to a contractual obligation Provider System Control: 230920E03109 SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 Page of 12.2 Claim Payment Advice Example ANSI X 12 ST 835 3207 BPR I 175.11 C CHK 20230925 TRN 1 97CF0000000411 207661234 DTM 405 20230918 N1 PR SUMMACARE N3 1200 E. MARKET STREET SUITE 400 N4 AKRON OH 44305 N1 PE HEALTHY HOSPITAL FI 123456789 N3 PO BOX 625 N4 BURLINGTON VT 05402 REF PQ V299 LX 1 CLP 330866922 1 583.7 175.11 13 230920E03109 13 1 NM1 QC 1 DOE JONATHAN MI 98765432103 NM1 IL 1 DOE JONATHAN MI 987654321 NM1 82 2 HEALTHY HOSPITAL XX 1234567890 DTM 232 20230902 DTM 233 20230902 SVC HC:73610 297.40 89.22 320 1 DTM 472 20230902 CAS CO 45 208.18 REF E9 PA AMT B6 89.22 SVC HC:73630 286.30 85.89 320 1 DTM 472 20230902 CAS CO 45 200.41 REF E9 PA AMT B6 85.89 SE 22 3207 SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 13 Version History The following Version History is provided to easily identify updates from the last version of this Companion Guide. Page of Version Date Updated Update 1.0 April 2023 Added: 9.1 Federal No Surprises Act (NSA) SummaCare complies with both federal and state NSA requirements. When RARC code N862 is found in the LQ segment, please reference additional information regarding federal NSA on SummaCare.com using the following link: https: www.summacare.com no-surprises-act 1.1 February 2024 Update: Examples given on pages 9 and 10 were updated with more current information. 14 Frequently Asked Questions - FAQ 1. What is Electronic Data Interchange? Electronic Data Interchange (EDI) allows providers to submit claims, retrieve remittance advices and retrieve claim file acknowledgements from their computer system to the insurance carrier or clearinghouse. 2. Can I receive my payment and Explanation of Payment Electronically (EOP)? Yes. Providers can receive an Electronic Fund Transfer (EFT) Automated Clearing House (ACH) payment after an EFT Registration form is completed and mailed back to SummaCare. Providers may review their EOP utilizing SummaCare's Provider self service tool of Plan Central. To register or to locate the EFT Registration form please go to http: www.summacare.com Provider ResourcesAndSelfServices.aspx. 3. Do you send data on all claims or just paid claims? We send data on all paid, denied and zero dollar charge claims. Data is not returned on electronic claims rejected at time of submission or claims in process in our system. 4. Do you send paper Explanation of Payment along with the electronic version? No, SummaCare will turn off the paper Explanation of Payments (EOP) once a provider starts receiving the 835 transaction. The provider may access Plan Central to review a Portable Document Format (PDF) image of their EOP by going to the following SummaCare website http: www.summacare.com Provider ResourcesAndSelfServices.aspx. 5. As a provider can I receive my 835 directly from SummaCare? Yes, SummaCare can set up a direct File Transfer Protocol (FTP) secure internet connection for the provider to directly pick up their 835 from SummaCare. SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 | /kaggle/input/edi-db-835-837/HIPAA SummaCare 835 Companion Guide 5010.pdf | cc2a69e2b30150b39da3b2fb5d2927af | cc2a69e2b30150b39da3b2fb5d2927af_0 |
Stedi maintains this guide based on public documentation from Security Health. Contact Security Health for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment Advice (X221A1) X12 Release 5010 Revised November 20, 2023 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution. Delimiters Segment Element Component Repetition View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view security-health health-care-claim-paymentadvice- x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE POWERED BY Build EDI implementation guides at stedi.com 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 1 124 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0100 Transaction Set Header Max use 1 Required BPR 0200 Financial Information Max use 1 Required TRN 0400 Reassociation Trace Number Max use 1 Required CUR 0500 Foreign Currency Information Max use 1 Optional REF 0600 Receiver Identification Max use 1 Optional REF 0600 Version Identification Max use 1 Optional DTM 0700 Production Date Max use 1 Optional Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional Detail Header Number Loop LX 0030 Header Number Max use 1 Required TS3 0050 Provider Summary Information Max use 1 Optional TS2 0070 Provider Supplemental Summary Information Max use 1 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 2 124 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Corrected Patient Insured Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Insured Name Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional REF 0400 Rendering Provider Identification Max use 10 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Statement From or To Date Max use 2 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 3 124 Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 4 124 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250130 0724 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 5 124 Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 6 124 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 7 124 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HP XXXXXXX XXXX 20250130 1743 0000 X 005010X22 1A1 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 8 124 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X221A1 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 9 124 Heading ST 0100 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 835 0001 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 10 124 BPR 0200 Heading BPR Financial Information To indicate the beginning of a Payment Order Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and or information from payer to payee to occur Usage notes Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPR H 000000000000000 D CHK CCP 01 XXXXXXXX D A X 1391572880 XXXXXXXXX 01 XXXXX DA XXX 2025013 0 If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Sender DFI Identifier (BPR-07) is present, then the other is required If Account Number Qualifier (BPR-08) is present, then Sender Bank Account Number (BPR-09) is required If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-12) or Receiver or Provider Bank ID Number (BPR-13) is present, then the other is required If Account Number Qualifier (BPR-14) is present, then Receiver or Provider Account Number (BPR-15) is required Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties H Notification Only Use this code when the actual provider payment (BPR02) is zero and the transaction is not being used for Prenotification of Future Transfers. This indicates remittance information without any associated payment. I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount BPR02 specifies the payment amount. Usage notes Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). BPR-03 478 Credit or Debit Flag Code Identifier (ID) Required Code indicating whether amount is a credit or debit 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 11 124 C Credit Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment. D Debit Use this code to indicate a debit to the payer's account and a credit to the provider's account, initiated by the provider at the instruction of the payer. Extreme caution must be used when using Debit transactions. Contact your VAB for information about debit transactions. The rest of this segment and document assumes that a credit payment is being used. BPR-04 591 Payment Method Code Identifier (ID) Required Code identifying the method for the movement of payment instructions ACH Automated Clearing House (ACH) Use this code to move money electronically through the ACH, or to notify the provider that an ACH transfer was requested. When this code is used, see BPR05 through BPR15 for additional requirements. CHK Check Use this code to indicate that a check has been issued for payment. BPR-05 812 Payment Format Code Identifier (ID) Optional Code identifying the payment format to be used CCP Cash Concentration Disbursement plus Addenda (CCD ) (ACH) Use the CCD format to move money and up to 80 characters of data, enough to reassociate dollars and data when the dollars are sent through the ACH and the data is sent on a separate path. The addenda must contain a copy of the TRN segment. BPR-06 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) When using this transaction set to initiate a payment, all or some of BPR06 through BPR16 may be required, depending on the conventions of the specific financial channel being used. BPR06 and BPR07 relate to the originating depository financial institution (ODFI). Usage notes BPR06 through BPR09 relate to the originating financial institution and the originator's account (payer). 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. BPR-07 507 Sender DFI Identifier Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 12 124 Use this number for the identifying number of the financial institution sending the transaction into the applicable network. SHP s Number BPR-08 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR08 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR09. DA Demand Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order. Usage notes Use this number for the originator's account number at the financial institution. SHP s Account Number BPR-10 509 Payer Identifier String (AN) Optional A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. BPR10 shall be mutually established between the originating depository financial institution (ODFI) and the company originating the payment. 1391572880 BPR-11 510 Originating Company Supplemental Code Min 9 Max 9 String (AN) Optional A code defined between the originating company and the originating depository financial institution (ODFI) that uniquely identifies the company initiating the transfer instructions Usage notes Use this code to further identify the payer by division or region. The element must be left justified and space filled to meet the minimum element size requirements. If used, this code must be identical to TRN04, excluding trailing spaces. BPR-12 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) BPR12 and BPR13 relate to the receiving depository financial institution (RDFI). Usage notes BPR12 through BPR15 relate to the receiving financial institution and the receiver's account. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 13 124 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution receiving the transaction from the applicable network. Routing Number of Receiver or Provider Bank BPR-14 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR14 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR15. DA Demand Deposit BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR15 is the account number of the receiving company to be debited or credited with the payment order. Usage notes Use this number for the receiver's account number at the financial institution. Provider Account Number BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). Usage notes Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is NON', enter the date of the 835. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 14 124 TRN 0400 Heading TRN Reassociation Trace Number To uniquely identify a transaction to an application Usage notes This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. Example TRN 1 XXXX 1391572880 XX Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN02 provides unique identification for the transaction. Usage notes This number must be unique within the sender receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non- payment 835, this must be a unique remittance advice identification number. See 1.10.2.3, Reassociation of Dollars and Data, for additional information. Remittance Advice Number TRN-03 509 Payer Identifier String (AN) Required A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. TRN03 identifies an organization. Usage notes This must be a 1 followed by the payer's EIN (or TIN). 1391572880 TRN-04 127 Originating Company Supplemental Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN04 identifies a further subdivision within the organization. Usage notes If both TRN04 and BPR11 are used, they must be identical, excluding trailing spaces. Since BPR11 has a min max value of 9 9, whenever both are used, this element is restricted to a maximum size of 9. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 15 124 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 16 124 CUR 0500 Heading CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes When the CUR segment is not present, the currency of payment is defined as US dollars. Required when the payment is not being made in US dollars. If not required by this implementation guide, do not send. Example CUR PR XXX Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 17 124 REF 0600 Heading REF Receiver Identification To specify identifying information Usage notes This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee. Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example REF EV XX Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 18 124 REF 0600 Heading REF Version Identification To specify identifying information Usage notes Update this reference number whenever a change in the version or release number affects the 835. (This is not the ANSI ASCX12 version number as reported in the GS segment.) Required when necessary to report the version number of the adjudication system that generated the claim payments in order for the payer to resolve customer service questions from the payee. If not required by this implementation guide, do not send. Example REF F2 XXX Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 19 124 DTM 0700 Heading DTM Production Date To specify pertinent dates and times Usage notes If your adjudication cycle completed on Thursday and your 835 is produced on Saturday, you are required to populate this segment with Thursday's date. Required when the cut off date of the adjudication system remittance run is different from the date of the 835 as identified in the related GS04 element. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example DTM 405 20250130 Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes Report the end date for the adjudication production cycle for claims included in this 835. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 20 124 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading Payer Identification Loop N1 Payer Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information for the payer. The payer's secondary identifying reference number is provided in N104, if necessary. Example N1 PR SECURITY HEALTH PLAN XV XXXXX If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name String (AN) Required Free-form name ADVOCARE FAMILY HEALTH CENTER MEDICAID SECURITY HEALTH PLAN TPA N1-03 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). N1-04 67 Payer Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 21 124 N3 1000 Heading Payer Identification Loop N3 Payer Address To specify the location of the named party Example N3 XX XXXX Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 22 124 N4 1100 Heading Payer Identification Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXXXX XX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 23 124 REF 1200 Heading Payer Identification Loop REF Additional Payer Identification To specify identifying information Usage notes The ID available in the TRN and N1 segments must be used before using the REF segment. Required when additional payer identification numbers beyond those in the TRN and Payer N1 segments are needed. If not required by this implementation guide, may be sent at sender's discretion, but cannot be required by the receiver. Example REF HI XXXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number For Medicare carriers or intermediaries, use this qualifier for the Medicare carrier or intermediary ID number. For Blue Cross and Blue Shield Plans, use this qualifier for the Blue Cross Blue Shield association plan code. EO Submitter Identification Number This is required when the original transaction sender is not the payer or is identified by an identifier other than those already provided. This is not updated by third parties between the payer and the payee. An example of a use for this qualifier is when identifying a clearinghouse that created the 835 when the health plan sent a proprietary format to the clearinghouse. HI Health Industry Number (HIN) NF National Association of Insurance Commissioners (NAIC) Code This is the preferred value when identifying the payer. REF-02 127 Additional Payer Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 24 124 PER 1300 Heading Payer Identification Loop PER Payer Business Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send. Example PER CX PROVIDER RELATIONS TE 8005481224 FX X EX X X Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PROVIDER RELATIONS PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number TE Telephone 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 25 124 PER-04 364 Payer Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable 8005481224 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 26 124 PER 1300 Heading Payer Identification Loop PER Payer Technical Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required to report technical contact information for this remittance advice. Example PER BL XXXXXX EM XXXXX UR XX EX XXX Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail TE Telephone Recommended UR Uniform Resource Locator (URL) Use only when there is no central telephone number for the payer entity. PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 27 124 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile TE Telephone UR Uniform Resource Locator (URL) PER-06 364 Payer Technical Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile UR Uniform Resource Locator (URL) PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 28 124 1000A Payer Identification Loop end PER 1300 Heading Payer Identification Loop PER Payer WEB Site To identify a person or office to whom administrative communications should be directed Usage notes Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PER IC UR XX Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 29 124 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading Payee Identification Loop N1 Payee Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information of the payee. The identifying reference number is provided in N104. Example N1 PE XXX FI XX Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number. XX Centers for Medicare and Medicaid Services National Provider Identifier This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate. N1-04 67 Payee Identification Code Min 2 Max 80 String (AN) Required Code identifying a party or other code This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 30 124 N3 1000 Heading Payee Identification Loop N3 Payee Address To specify the location of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N3 XXXX XXXXX Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 31 124 N4 1100 Heading Payee Identification Loop N4 Payee City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N4 XXXXX XX XXXXXXX XX Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 32 124 REF 1200 Heading Payee Identification Loop REF Payee Additional Identification To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example REF PQ XXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PQ Payee Identification TJ Federal Taxpayer's Identification Number This information must be in the N1 segment unless the National Provider ID or the Health Plan Identifier (HPID) or Other Entity Identifier (OEID) was used in N104. For individual providers as payees, use this number to represent the Social Security Number. TJ also represents the Employer Identification Number (EIN). According to the IRS, TIN and EIN can be used interchangeably. REF-02 127 Additional Payee Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 33 124 RDM 1400 Heading Payee Identification Loop RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes Required when BPR01 U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM BM XXXXX XXX Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 34 124 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 35 124 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 0 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 36 124 TS3 0050 Detail Header Number Loop TS3 Provider Summary Information To supply provider-level control information Usage notes TS301 identifies the subsidiary provider. The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000. Required for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity i.e., the corporate office of a hospital chain. If not required by this implementation guide, do not send. Example TS3 X XX 20250130 0 00000000000 000000000 0 0000000 000000000 0000000000000 00 0000000 0 0000000000 00000000000 000 Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of | /kaggle/input/edi-db-835-837/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_0 |
the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 34 124 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 35 124 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 0 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 36 124 TS3 0050 Detail Header Number Loop TS3 Provider Summary Information To supply provider-level control information Usage notes TS301 identifies the subsidiary provider. The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000. Required for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity i.e., the corporate office of a hospital chain. If not required by this implementation guide, do not send. Example TS3 X XX 20250130 0 00000000000 000000000 0 0000000 000000000 0000000000000 00 0000000 0 0000000000 00000000000 000 Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes When reporting a TS3 segment for professional claims and the claims are not all for the same place of service, report a place of service of 11 (Office) as the default value. When reporting a TS3 segment for pharmaceutical claims and the claims are not all for the same place of service, report a place of service of 99 (Other unlisted facility) as the default value. TS3-03 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year TS303 is the last day of the provider's fiscal year. Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 37 124 Use this date for the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known, use December 31st of the current year. TS3-04 380 Total Claim Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity TS304 is the total number of claims. Usage notes This is the total number of claims. TS3-05 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount TS305 is the total of reported charges. Usage notes This is the total reported charges for all claims. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all 782 elements. TS3-13 782 Total MSP Payer Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS313 is the total Medicare Secondary Payer (MSP) primary payer amount. Usage notes See TR3 note 3. TS3-15 782 Total Non-Lab Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS317 is the Health Care Financing Administration Common Procedural Coding System (HCPCS) reported charges. Usage notes See TR3 note 3. TS3-18 782 Total HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 38 124 Monetary amount TS318 is the total Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes See TR3 note 3. TS3-20 782 Total Professional Component Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS320 is the total professional component amount. Usage notes The professional component amount must also be reported in the CAS segment with a Claim Adjustment Reason Code value of 89. See TR3 note 3. TS3-21 782 Total MSP Patient Liability Met Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS321 is the total Medicare Secondary Payer (MSP) patient liability met. Usage notes See TR3 note 3. TS3-22 782 Total Patient Reimbursement Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS322 is the total patient reimbursement. Usage notes See TR3 note 3. TS3-23 380 Total PIP Claim Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS323 is the total periodic interim payment (PIP) number of claims. Usage notes See TR3 note 3. TS3-24 782 Total PIP Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 39 124 See TR3 note 3. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 40 124 TS2 0070 Detail Header Number Loop TS2 Provider Supplemental Summary Information To provide supplemental summary control information by provider fiscal year and bill type Usage notes This segment provides summary information specific to an iteration of the LX loop (Table 2). Each element represents the total value for the provider bill type combination in this loop 2000 iteration. Required for Medicare Part A. If not required by this implementation guide, do not send. Example TS2 00000000 000000 00000000000000 000000000 0000 000000000 000 0000000000000 000000000000 00000000 00 000000 00 0000000000000 00000000 0000000 00000 0 00 000000000000 0000000000000 000000000000000 Max use 1 Optional TS2-01 782 Total DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS201 is the total diagnosis related group (DRG) amount. Usage notes This includes: operating federal-specific amount, operating hospital-specific amount, operating Indirect Medical Education amount, and operating Disproportionate Share Hospital amount. It does not include any operating outlier amount. See TR3 note 2. TS2-02 782 Total Federal Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS202 is the total federal specific amount. Usage notes See TR3 note 2. TS2-03 782 Total Hospital Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS203 is the total hospital specific amount. Usage notes See TR3 note 2. TS2-04 782 Total Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS204 is the total disproportionate share amount. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 41 124 Usage notes See TR3 note 2. TS2-05 782 Total Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS205 is the total capital amount. Usage notes This includes: capital federal-specfic amount, hospital federal-specfic amount, hold harmless amount, Indirect Medical Education amount, Disproportionate Share Hospital amount, and the exception amount. It does not include any capital outlier amount. See TR3 note 2. TS2-06 782 Total Indirect Medical Education Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS206 is the total indirect medical education amount. Usage notes See TR3 note 2. TS2-07 380 Total Outlier Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS207 is the total number of outlier days. Usage notes See TR3 note 2. TS2-08 782 Total Day Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS208 is the total day outlier amount. Usage notes See TR3 note 2. TS2-09 782 Total Cost Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS209 is the total cost outlier amount. Usage notes See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 42 124 TS210 is the diagnosis related group (DRG) average length of stay. Usage notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS211 is the total number of discharges. Usage notes This is the discharge count produced by PPS PRICER SOFTWARE. See TR3 note 2. TS2-12 380 Total Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS212 is the total number of cost report days. Usage notes See TR3 note 2. TS2-13 380 Total Covered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS213 is the total number of covered days. Usage notes See TR3 note 2. TS2-14 380 Total Noncovered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS214 is total number of non-covered days. Usage notes See TR3 note 2. TS2-15 782 Total MSP Pass-Through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer. Usage notes See TR3 note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 43 124 Numeric value of quantity TS216 is the average diagnosis-related group (DRG) weight. Usage notes See TR3 note 2. TS2-17 782 Total PPS Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS217 is the total prospective payment system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-18 782 Total PPS Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-19 782 Total PPS DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 44 124 2100 Claim Payment Information Loop Max 1 Required CLP 0100 Detail Header Number Loop Claim Payment Information Loop CLP Claim Payment Information To supply information common to all services of a claim Usage notes For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations. Example CLP XXXX 20 00000000000 000000000000 0 MB XXX X X X XXXX 000000000000 000 Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format). CLP-02 1029 Claim Status Code Identifier (ID) Required Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization Usage notes To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code. 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied Usage of this code would apply if the Patient Subscriber is not recognized, and the claim was not forwarded to another payer. 19 Processed as Primary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 20 Processed as Secondary, Forwarded to Additional Payer(s) 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 45 124 When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 22 Reversal of Previous Payment See section 1.10.2.8 for usage information. 23 Not Our Claim, Forwarded to Additional Payer(s) Usage of this code would apply if the patient subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required. 25 Predetermination Pricing Only - No Payment CLP-03 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CLP-04 782 Claim Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 46 124 Code identifying type of claim Usage notes For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2- 005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835. The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer. 12 Preferred Provider Organization (PPO) This code is also used for Blue Cross Blue Shield participating provider arrangements. 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance This code is also used for Blue Cross Blue Shield non-participating provider arrangements. 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical CH Champus DS Disability HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use this code for the Black Lung Program. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 47 124 Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 48 124 CAS 0200 Detail Header Number Loop Claim Payment Information Loop CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note 1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CAS PR X 00000000000 00000000000 XXX 00000 000000 000000 X 000000000000000 0000000000 XXX 0000 0000 000 XXX 00000 000000000 XXXX 00000000000000 00000 0 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 49 124 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 50 124 A positive value decreases the covered days, and a negative number increases the covered days. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 51 124 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 52 124 Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 53 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Patient Insured Name To supply the full name of an individual or organizational entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send. Example NM1 74 2 XXXXX X X XXXXXX C XX Variants (all may be used) NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 74 Corrected Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 54 124 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 55 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1 PR 2 XXXXX PP XXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 56 124 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 57 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1 TT 2 XXXXX PP XXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 58 124 PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Crossover Carrier Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 59 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Insured Name To supply the full name of an individual or organizational entity Usage notes In the case of Medicare and Medicaid, the insured patient is always the subscriber and this segment is not used. Required when the original claim reported the insured or subscriber (for example 837 2010BA loop Subscriber Name NM1 Segment) that is different from the patient. If not required by this implementation guide, do not send. This segment contains the same information as reported on the claim (for example 837 2010BA loop Subscriber Name NM1 Segment when the patient was reported in the 2010CA loop Patient Name NM1 Segment). Example NM1 IL 1 XXXXXX XXXXXX X XXX MI XX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 60 124 Individual middle name or initial Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes For example, use when necessary to differentiate between a Junior and Senior under the same contract. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) MI Member Identification Number The code MI is intended to identify that the subscriber's identification number as assigned by the payer will be conveyed in NM109. Payers use different terminology to convey the same number, therefore, the 835 workgroup recommends using MI (Member Identification number) to convey the same categories of numbers as represented in the 837 IGs for the inbound claims. NM1-09 67 Subscriber Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes Security Health Plan Member ID 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 61 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1 GB 2 XXX XXX XXXXXX XXXXXX II XXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 62 124 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 63 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1 QC 1 XX XXXXXX XXXX XXXX MI XXXXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 64 124 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) MI Member Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Security Health Plan Member ID 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 65 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1 82 1 XXXX XXX XXXXXX XXX XX XXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 66 124 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number FI Federal Taxpayer's Identification Number This is the preferred ID until the National Provider ID is mandated and applicable. For individual providers as payees, use this qualifier to represent the Social Security Number. MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 67 124 MIA 0330 Detail Header Number Loop Claim Payment Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA 0000000 00000000000000 00000 000000000 XX 000 00000000000 0000000 0 000 0 00000000000000 000000 000000 00000000000000 00000 000000000 000000 0000 000 0000 000000 XXXXX XXX XX XXXXXX 000000000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied | /kaggle/input/edi-db-835-837/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_1 |
- Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 66 124 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number FI Federal Taxpayer's Identification Number This is the preferred ID until the National Provider ID is mandated and applicable. For individual providers as payees, use this qualifier to represent the Social Security Number. MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 67 124 MIA 0330 Detail Header Number Loop Claim Payment Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA 0000000 00000000000000 00000 000000000 XX 000 00000000000 0000000 0 000 0 00000000000000 000000 000000 00000000000000 00000 000000000 000000 0000 000 0000 000000 XXXXX XXX XX XXXXXX 000000000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 68 124 Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 69 124 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 70 124 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 71 124 MOA 0350 Detail Header Number Loop Claim Payment Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA 000 0000000 XX X XXXXX XXXX XXXX 000000000 0 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 72 124 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 73 124 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REF IG X Variants (all may be used) REF Rendering Provider Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number Use this code when conveying the Group Number in REF02. 1W Member Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. IG Insurance Policy Number Use this code when conveying the Policy Number in REF02. REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes For IL, Security Health Plan s carrier identifier For 1W, Member SSN For F8, Security Health Plan s Original Claim Identifier For IG, Security Health Plan s policy identifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 74 124 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Rendering Provider Identification To specify identifying information Usage notes The NM1 segment always contains the primary reference number. Required when additional rendering provider identification numbers not already reported in the Provider NM1 segment for this claim were submitted on the original claim and impacted adjudication. If not required by this implementation guide, do not send. Example REF LU XXXXX Variants (all may be used) REF Other Claim Related Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 75 124 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM 050 20250130 Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 76 124 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM 036 20250130 Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 77 124 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 232 20250130 Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 78 124 PER 0600 Detail Header Number Loop Claim Payment Information Loop PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PER CX XXX FX XXX FX XXX EX XXXXX If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 79 124 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 80 124 AMT 0620 Detail Header Number Loop Claim Payment Information Loop AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT I 000000000000000 Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). I Interest See section 1.10.2.9 for additional information. AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 81 124 QTY 0640 Detail Header Number Loop Claim Payment Information Loop QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTY LE 00000 Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual LE Life-time Reserve - Estimated NE Non-Covered - Estimated NR Not Replaced Blood Units OU Outlier Days PS Prescription VS Visits ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 82 124 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78 25 ). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVC HC XXXX XX XX XX XX 000 000 XXXXX 00000000000 0 NU XXXX XX XX XX XX XXX 00 Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 83 124 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format N6 National Health Related Item Code in 4-6 Format This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names National Health Related Item Code in 4-6 Format Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. NU National Uniform Billing Committee (NUBC) UB92 Codes UI U.P.C. Consumer Package Code (1-5-5) This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names U.P.C. Consumer Package Code (1-5-5) Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. WK Advanced Billing Concepts (ABC) Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used in transactions covered under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 84 124 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier Max use 1 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 85 124 To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes WK Advanced Billing Concepts (ABC) Codes This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 86 124 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 87 124 DTM 0800 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 150 20250130 Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 88 124 CAS 0900 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS PI XXX 000 0000000000 XXX 000000000 0 XXX 000 00000000000 0000000000 XX 000000000000 00000 XX 0 0000 00000000000000 XX 0000 0 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 89 124 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 90 124 A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 91 124 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 92 124 Usage notes See CAS02. CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 93 124 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF 0K X Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 94 124 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF 6R X Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 95 124 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REF HPI XXXXXX Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 96 124 REF 1000 Detail Header Number Loop Claim Payment Information | /kaggle/input/edi-db-835-837/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_2 |
Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 94 124 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF 6R X Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 95 124 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REF HPI XXXXXX Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 96 124 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REF BB XXX Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification BB Authorization Number REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 97 124 AMT 1100 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT B6 0 Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 98 124 QTY 1200 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTY ZK 000 Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 99 124 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQ RX X Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes RX National Council for Prescription Drug Programs Reject Payment Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 100 124 Summary PLB 0100 Summary PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLB XXXX 20250130 HM XXX 000000000000 XX XXXXX 00 000000000 XX XXXX 00 XX XXXXXX 000000000 XX XXXX X 00000 XX XXXXXX 0000 If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use 1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 101 124 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AH Origination Fee This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims. AM Applied to Borrower's Account See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this code to identify the loan repayment amount. This is capitation specific. AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 102 124 BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CR Capitation Interest This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CS Adjustment Provide supporting identification information in PLB03-2. CT Capitation Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CV Capital Passthru CW Certified Registered Nurse Anesthetist Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. FC Fund Allocation This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund must be identified in PLB03-2. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 103 124 Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source). C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Use when necessary to assist the receiver in identifying, tracking or reconcilling the adjustment. See sections 1.10.2.10 (Capitation and Related Payments), 1.10.2.5 (Advanced Payments and Reconciliation) and 1.10.2.12 (Balance Forward Processing) for further information. PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PLB04 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. PLB-05 C042 Adjustment Identifier Max use 1 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 104 124 To provide the category and identifying reference information for an adjustment - PLB05 is the adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB06 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-07 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB07 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-08 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB08 is the adjustment amount. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 105 124 Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-09 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-10 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB10 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-11 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB11 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 106 124 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-12 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB12 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-13 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB13 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 107 124 Summary end SE 0200 Summary SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 0000 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 108 124 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 000000 0000000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 109 124 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 00000 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 110 124 EDI Samples Example 1: Dollars and Data Sent Separately ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 112233 BPR I 1100 C ACH CCP 01 888999777 DA 24681012 1391572880 01 111333555 DA 144444 20190316 TRN 1 71700666555 1391572880 DTM 405 20190314 N1 PR ADVOCARE N3 10 SOUTH AVENUET N4 RAPID CITY SD 55111 PER BL JOHN WAYNE TE 8005551212 EX 123 N1 PE ACME MEDICAL CENTER XX 5544667733 REF TJ 777667755 LX 1 CLP 5554555444 1 800 500 300 12 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT AU 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 12 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT AU 1200 SVC HC 93555 1200 600 DTM 472 20190310 CAS PR 1 600 AMT B6 1200 SE 26 112233 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 111 124 Example 2: Multiple Claims Single Check ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1391572880 REF EV XYZ CLEARINGHOUSE N1 PR ADVOCARE N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC XX 9999947036 REF TJ 212121212 LX 1 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 DOE SANDY MI SJD11112 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 119 74 12 119932404007801 11 1 NM1 QC 1 DOE SALLY MI SJD11111 NM1 IL 1 DOE JOHN MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 74 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 12 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 112 124 AMT B6 25 SVC AD D0220 25 0 DTM 472 20190324 CAS PR 3 14 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 0 DTM 472 20190324 CAS PR 3 10 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 1145 14 902 12 119932404007801 11 1 NM1 QC 1 SMITH SAM MI SJD11116 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 14 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D2790 940 0 DTM 472 20190324 CAS PR 3 756 CAS CO 45 184 SVC AD D2950 180 0 DTM 472 20190324 CAS PR 3 146 CAS CO 45 34 CLP 7722337 1 348 16.8 44.2 12 119932404007801 11 1 NM1 QC 1 JONES SAM MI SJD11122 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 28 SVC AD D4342 125 0 DTM 472 20190313 CAS CO 45 125 SVC AD D4381 43 0 DTM 472 20190313 CAS PR 3 33 CAS CO 45 10 SVC AD D2950 180 16.8 DTM 472 20190313 CAS PR 3 11.2 CAS CO 45 152 AMT B6 28 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 JONES SALLY MI SJD11133 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190321 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 113 124 DTM 472 20190321 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190321 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190321 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190321 CAS CO 45 24 AMT B6 49 CLP 7722337 1 179 108 12 119932404007801 11 1 NM1 QC 1 DOE SAM MI SJD99999 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 108 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 129 82 12 119932404007801 11 1 NM1 QC 1 DOE SUE MI SJD88888 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 CLP 7722337 1 221 144 12 119932404007801 11 1 NM1 QC 1 DOE DONNA MI SJD77777 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 144 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0330 92 62 DTM 472 20190324 CAS CO 45 30 AMT B6 62 SVC AD D1120 54 37 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 114 124 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 SE 183 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 115 124 Example 3: Claim Specific Negotiated Discount ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 132 C CHK 20190331 TRN 1 12345 1391572880 REF EV CLEARINGHOUSE N1 PR ADVOCARE N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC FI 999994703 LX 1 CLP 7722337 1 226 132 12 119932404007801 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 131 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 131 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 131 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 131 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 131 24 AMT B6 49 SE 35 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 116 124 Example 4: Claim Adjustment Reason Code 45 ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 80.00 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 400 80 MC CLAIMNUMBER 11 1 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004074627 AMT AU 150 SVC HC 99213 150 80 1 DTM 472 20190101 CAS CO 45 70 AMT B6 80 SVC HC 85003 100 0 1 DTM 472 20190101 CAS CO 204 100 SVC HC 36415 150 0 1 DTM 472 20190101 CAS CO 97 150 SE 33 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 117 124 Example 5a: Line Service Tax impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 11.06 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 36.20 11.06 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 DTM 050 20170113 AMT AU 36.20 SVC HC 99214 26.2 3.06 DTM 472 20170109 CAS CO 45 23.2 137 -.06 REF 6R B1 AMT B6 3 SVC HC 36415 10 8 DTM 472 20170109 CAS CO 45 2 REF 6R B2 AMT B6 8 SE 34 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 118 124 Example 5b: Line Service Bonuses impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 12.00 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 12 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 12 DTM 472 20170109 CAS CO 45 5 161 -2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 30 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 119 124 Example 5c: Line Service Penalty impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8.00 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 8 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 8 DTM 472 20170109 CAS CO 45 5 B4 2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 30 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 120 124 Example 6: Not Covered Not Authorized Inpatient Facility claim days ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8000.00 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 40000 8000 MC CLAIMNUMBER 11 1 CAS CO 197 2000 1 45 30000 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 232 20190101 DTM 233 20190105 DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004001212 AMT AU 38000 QTY CA 4 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 121 124 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 120.03 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 04777796TLC777122 1 155 120.03 13 8838888212 11 1 NM1 QC 1 MASTERS MARVIN L MI 80444444403 NM1 IL 1 CABLE MABEL MI 80444444403 NM1 74 1 MASTERS MARVIN C 80444444401 NM1 82 1 SHELTON MD BLAKE XX 1666666666 REF 1L 28 DTM 232 20191114 DTM 233 20181114 DTM 050 20181119 AMT AU 155 SVC HC 99393 155 120.03 1 DTM 472 20181114 CAS CO 45 34.97 REF 6R 22261822 AMT B6 120.03 SE 32 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 122 124 Example 8b: Claim submitted with incorrect subscriber name and ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 35.06 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 02333TLC222222 1 115 35.06 35 13 8333333214 11 1 NM1 QC 1 KEATON ALEX P MI 80000006006 NM1 IL 1 THOMAS JASON MI 80000006006 NM1 74 1 JEROME C 80000006001 NM1 82 1 BLOOD MD RED N XX 1888888886 REF 1L 28 DTM 232 20191113 DTM 233 20191113 DTM 050 20191119 AMT AU 115 SVC HC 99213 115 35.06 1 DTM 472 20191113 CAS CO 45 44.94 CAS PR 3 35 REF 6R 22261389 AMT B6 70.06 SE 33 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 123 124 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 2415.25 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 05444444TLC999999 1 3903 2415.25 13 8777777782 21 1 NM1 QC 1 GONZALES SAMMY MI 80455555502 NM1 IL 1 LAPLANTE FERN MI 80455555502 NM1 74 1 R NM1 82 1 GOOD MD ROBERT B XX 19999999987 REF 1L 28 DTM 232 20191101 DTM 233 20191101 DTM 050 20191114 AMT AU 3903 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF 6R 22215592 AMT B6 2415.25 SE 32 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 124 124 | /kaggle/input/edi-db-835-837/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_3 |
837 Health Care Claim Companion Guide Professional and Institutional Revised December 2011 Table of Contents Introduction........................................................................................................... 3 Purpose................................................................................................................ 3 References........................................................................................................... 3 Additional information........................................................................................... 4 Delimiters Supported......................................................................................... 4 Maximum Limitations......................................................................................... 4 Submission Specifications................................................................................. 4 Interchange Control Header Specification............................................................ 6 Interchange Control Trailer Specification.............................................................. 6 Functional Group Header Specification................................................................ 7 Functional Group Trailer Specification.................................................................. 7 837 Professional Claim Transaction Specifications.............................................. 8 837 Institutional Claim Transaction Specifications.............................................. 10 2 Introduction The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was passed in order to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs of the health care industry. This act required the Department of Health and Human Services (HHS) to adopt standards that support the electronic data interchange (EDI) of health care transactions. In order for the industry to achieve its desired goal, all organizations involved in electronic interchange of data must comply with the standard transactions and code sets that have been developed. These guidelines are outlined in the ANSI X12N 837 Health Care Claims transaction implementation guides. By adopting these standards the efficiency and effectiveness of the health care will improve by encouraging the use of electronic data interchange throughout the industry. This latest version of the Companion Guide contains the changes necessary to ensure compliance with 45 CFR Part 162, CMS-009-F. Purpose The purpose of this document is to provide submitters with the necessary information to successfully submit electronic claims to Advanced Behavioral Health, Inc (ABH). This companion guide should be used in combination with the ANSI X12N 837 implementation guides. These guides are available from Washington Publishing Company on their website at www.wpc- edi.com hipaa. Types of transactions accepted by ABH are: 837 Professional Health Care Claim ASC X12 837 837 Institutional Health Care Claim ASC X12 837 For those submitters who have previously submitted State of CT General Assistance batch claims electronically, no changes have been made other than the names of the parties involved. For those submitters who have not submitted electronic claims in the past, this companion guide will describe specific requirements necessary for processing claims through Advanced Behavioral Health s system. This guide in no way replaces any requirements that are found in the ANSI X12N implementation guides. References Listed below are some additional websites containing information that may be helpful during the implementation process: Accredited Standards Committee (ASC X12N) http: www.x12n.org Centers for Medicare and Medicaid Services (CMS) http: www.cms.hhs.gov hipaa United States Department of Health and Human Services (DHHS) http: aspe.hhs.gov admnsimp Washington Publishing Company http: wpc-edi.com hipaa 3 Additional information Delimiters Supported A delimiter is a character that is used to separate data elements, or mark the end of a segment. The preferred delimiters for electronic data are an ( ) asterisk for separation of data elements, a (:) colon for separation of sub-elements, and ( ) tilde for indication of a segment end. Other delimiters will be accepted according to the ANSI X12N guidelines. Note that once a delimiter has been specified, it cannot be used in the data elements transferred or it will cause the file to be rejected. Maximum Limitations The 837 transaction is designed to submit one or more claims per billing provider. The hierarchy built into the structure is billing provider, subscriber, patient, claim, and claim service. The number of times that each of these loops may repeat is defined in the implementation guides. For example, there cannot be more than 100 claims per client, and no more than 50 service lines per professional claim 999 service lines per institutional claim. ABH will require that only one interchange be submitted per transaction. In addition, there may be only one type of claim (institutional or professional) submitted per interchange, and therefore per file. When files are validated, after being submitted to ABH, they will be checked and accepted (pass) or rejected (fail) based on the entire file s formatting. Therefore, partial files will not be accepted. Providers will be notified of this response via a download page on the ABH website. If a file is rejected, the message will indicate to the provider what they will need to correct. If there are questions about any error messages that are unclear, please contact the ABH customer service for assistance. Submission Specifications Provider organizations who wish to submit electronic 837 transactions to Advanced Behavioral Health must have a valid submitter id and password. If you do not have this information you may acquire one by contacting the Customer Support at 800-606-3677 X6440 or downloading, completing and submitting the form on ABH s website at http: www.abhct.com resources_gabhp.asp. In addition, provider organizations wishing to submit batch claims electronically to ABH must submit one accepted, error free test file and receive verification that the file loaded successfully before submitting production files. In order to submit test files, an ID and password will be assigned by filling out the access form referenced above. The ID will allow submitters to submit only test files until the successful file has been received, at which time the ID will be activated for production files. Provider organizations who will be submitting their claims through the single data-entry claims system on the Internet will not need to test any files and will be able to start submitting claims as soon as they receive their ID and password. 4 If your provider organization utilizes a third-party health care clearinghouse or other agency to submit batch claim files, the organization must submit a copy of a signed Business Associate or Trading Partner agreement along with the access request form. The Department of Mental Health Addiction Services reserves the right to make final decisions regarding approval of access for third-party agencies. If you have further questions about obtaining access for a third- party agency, please contact our Provider Relations Department at (800) 606-3677, Ext. 6440. 5 Interchange Control Header Trailer Specifications Seg Data Element Name Usage Comments Expected Value ISA Interchange Control Header R ISA01 Authorization Information Qualifier R Use '03' Additional Data Identification to indicate that a login ID is present in ISA02. ISA02 Authorization Information R Information used for additional identification or authorization. Use the ABH Submitter ID as the login ID. ISA03 Security Information Qualifier R Use '01 Password to indicate that a password is present in ISA04. ISA04 Security Information R Additional security information identifying the sender. Use the ABH Submitter ID password. ISA05 Interchange ID Qualifier R Refer to the implementation guide for a list of valid qualifiers. ISA06 Interchange Sender ID R Refer to the implementation guide specifications. ISA07 Interchange ID Qualifier R Use 'ZZ' Mutually Defined ISA08 Interchange Receiver ID R Use 'ABH ' ISA09 Interchange Date R Date format YYMMDD ISA10 Interchange Time R Time format HHMM ISA11 Interchange Repitition Separator R ISA12 Interchange Control Version Number R Valid values: '00501' Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 Use the current standard approved for the ISA IEA envelope. ISA13 Interchange Control Number R The interchange control number must match the interchange trailer IEA02. This value is to be defined by the senders system. If not used, this field must be zero filled. ISA14 Acknowledgement Requested R Valid values: '0' No Acknowledgement Requested '1' Interchange Acknowledgement Requested ISA15 Usage Indicator R Valid values: 'P' Production 'T' Test This Usage Indicator should be set appropriately. When submitting initial tests use 'T', for all other files use 'P'. ISA16 Component Element Separator R The delimiter must be a unique character not found in any of the data included in the batch. This element will contain the delimiter that will be used to separate components within a data element. This value must be different from the element separator and segment terminator. Seg Data Element Name Usage Comments Expected Value IEA Interchange Control Trailer R IEA01 Number of Included Functional Groups R Count of the number of functional groups in the interchange. IEA02 Interchange Control Number R The interchange control number in IEA02 must match the interchange header value sent in ISA13. The interchange control numbers in the IEA and ISA segments will be compared. If the numbers do not match the file will be rejected. Header Trailer 6 Functional Group Header Trailer Specifications Seg Data Element Name Usage Comments Expected Value GS Functional Group Header R GS01 Functional Identifier Code R Valid values: 'HC' Health Care Claims (837) Use 'HC' Health Care Claims (837) GS02 Application Sender's Code R The sender defines this value. GS03 Application Receiver's Code R This field identifies how the file was received by ABH. Use 'EDI' for electronic transfer of data. GS04 Date R Date format CCYYMMDD GS05 Time R Time format HHMM. GS06 Group Control Number R The group control number in GS06 must be the same as the associated group trailer element (GE02). GS07 Responsible Agency Code R Valid values: 'X' Accredited Standards Committee X12 Use 'X' Accredited Standards Committee X12 GS08 Version Release Industry ID Code R Valid values: '005010X222A1' - Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003. '005010X223A2' - Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003. Use the current standard approved for publication by ASC X12. Seg Data Element Name Usage Comments Expected Value GE Functional Group Trailer R GE01 Number of Transaction Sets IncludedR Count of the number of transaction sets in the functional group. Only similar transaction sets may be included in the functional group. GE02 Group Control Number R The group control number in GE02 must match that sent in the group header (GS06). The group control numbers in the GE and GS segments will be compared. If the numbers do not match the file will be rejected. Header Trailer 7 837 Professional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value BHT Beginning of Hierarchical Transaction R BHT02 Transaction Set Purpose Code R Valid values: '00' Original '18' Reissue Case Use '00' Original. BHT06 Transaction Type Code R Use 'CH' for claims NM1 Submitter Name R NM109 Submitter Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use the ABH Submitter ID. NM1 Receiver Name R NM103 Receiver Name R Use 'Advanced Behavioral Health, Inc.' NM109 Receiver Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use 'ABH'. PRV Billing Pay-To Provider Specialty Information R PRV02 Provider Specialty Code Qualifier R Use 'PXC' PRV03 Provider Taxonomy Code R Send the providers taxonomy code. NM1 Billing Provider Name R NM108 Billing Provider Identification Code Qualifier R Use 'XX' NM109 Billing Provider Identifier R Send the Provider's National Provider ID (NPI) N4 Billing Provider City State Zip Code R N403 Billing Provider Zip Code R Send the Provider's 9-digit zip code. REF Billing Provider Secondary Identification S When NPI is submitted in NM108 109, the provider must send either their EIN or SSN in the REF loop. REF01 Reference Identification Qualifier R Use: 'EI' Tax ID (to indicate the provider's EIN) 'SY' SSN (to indicate the provider's SSN) REF02 Billing Provider Additional Identifier R Send the Provider's EIN SSN NM1 Subscriber Name R NM108 Identification Code Qualifier S Required if the subscriber is a person (NM102 1). Also required if the subscriber is the patient. Use 'MI' Member Identification Number. NM109 Subscriber Primary Identifier S Use the client's EMS ID. NM1 Payer Name R NM103 Payer Name R Destination Payer Name Use 'Advanced Behavioral Health, Inc.' NM108 Identification Code Qualifier R Use 'PI' Payer Identifier NM109 Payer Identifier R Destination Payer Identifier Use 'ABH'. CLM Claim Information R CLM01 Claims Submitter's Identifier R Patient's Account Number entered here will be returned on the EOB. NM1 Referring Provider Name S NM108 Identification Code Qualifier S Use 'XX'. NM109 Identification Code S Use the National Provider ID (NPI) of the referring provider. REF Referring Provider Secondary Identification S REF01 Reference Identification Qualifier R Required if a secondary number is necessary to identify the provider. The primary identifier should be sent in NM108 109 in this loop. Use 'G2' REF02 Referring Provider Secondary Identification R Header Loop 1000A - Submitter Name Loop 1000B - Receiver Name Loop 2010AA - Billing Provider Name Loop 2000A - Billing Pay-To Provider Specialty Information Loop 2010BA - Subscriber Name Loop 2010BB - Payer Name Loop 2300 - Claim Information Loop 2310A - Referring Provider Name 8 837 Professional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value NM1 Rendering Provider Secondary Identification S NM108 Identification Qualifier R Use 'XX'. NM109 Rendering Provider Identification R Use the National Provider ID (NPI) of the rendering provider. SV1 Professional Service R SV101 Composite Medical Procedure Identifier R SV101-1 Product Service ID Qualifier R Use 'HC' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes. SV101-3 SV101-4 SV101-5 SV101-6 Procedure Modifier S SV104 Quantity S Use whole number unit values. DTP Date - Service Date R DTP02 Date Time Period Qualifier R Valid values: 'D8' Single Date (CCYYMMDD) 'RD8' Range of Dates Use 'RD8' to specify a range of dates. The from and thru service dates should be sent for each service line. Loop 2400 - Service Line Loop 2310B - Rendering Provider Name 9 837 Institutional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value BHT Beginning of Hierarchical Transaction R BHT02 Transaction Set Purpose Code R Valid values: '00' Original '18' Reissue Case Use '00' Original. BHT06 Transaction Type Code R Use 'CH' for claims NM1 Submitter Name R NM109 Submitter Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use the ABH Submitter ID. NM1 Receiver Name R NM103 Receiver Name R Use 'Advanced Behavioral Health, Inc.' NM109 Receiver Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use 'ABH'. PRV Billing Pay-To Provider Specialty Information R PRV02 Provider Specialty Code Qualifier R Use 'PXC' PRV03 Provider Taxonomy Code R Send the providers taxonomy code. NM1 Billing Provider Name R NM108 Billing Provider Identification Code Qualifier R Use 'XX' NM109 Billing Provider Identifier R Send the Provider's National Provider ID (NPI) N4 Billing Provider City State Zip Code R N403 Billing Provider Zip Code R Send the Provider's 9-digit zip code. REF Billing Provider Secondary Identification S When NPI is submitted in NM108 109, the provider must send their EIN in the REF loop. REF01 Reference Identification Qualifier R Use: 'EI' Tax ID (to indicate the provider's EIN) REF02 Billing Provider Additional Identifier R Send the Provider's EIN NM1 Subscriber Name R NM108 Identification Code Qualifier S Required if the subscriber is a person (NM102 1). Also required if the subscriber is the patient. Use 'MI' Member Identification Number. NM109 Subscriber Primary Identifier S Use the client's EMS ID. NM1 Payer Name R NM103 Payer Name R Destination Payer Name Use 'Advanced Behavioral Health, Inc.' NM108 Identification Code Qualifier R Use 'PI' Payer Identifier NM109 Payer Identifier R Destination Payer Identifier Use 'ABH'. CLM Claim Information R CLM01 Claims Submitter's Identifier R Patient's Account Number entered here will be returned on the EOB. CLM05 Health Care Service Location Information R CLM05-3 Claim Frequency Type Code R UB-92 Type of Bill. Valid values: '1' - Admit through Discharge Claim '2' - Interim - First Claim '3' - Interim - Continuing Claim '4' - Interim - Last Claim '5' - Late Charge Only Use '1', '2', '3', '4', or '5' REF Original Reference Number (ICN DCN) S REF02 Original Reference Number (ICN DCN) R When submitting an Original Reference Number use the number with the prefix of 'RC'. HI Principal Procedure Information S HI01 Health Care Code Information R HI01-1 Code List Qualifier R Use 'BR' Health Care Financing Administration Common Procedural Coding System Principal Procedure. HI Other Procedure Information S HI01 Health Care Code Information R HI01-1 Code List Qualifier R Use 'BQ' Health Care Financing Administration Common Procedural Coding System. Loop 2010BA - Subscriber Name Loop 2010BB - Payer Name Header Loop 1000A - Submitter Name Loop 1000B - Receiver Name Loop 2010AA - Billing Provider Name Loop 2000A - Billing Pay-To Provider Specialty Information Loop 2300 - Claim Information 10 837 Institutional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value SV2 Institutional Service Line R SV202 Composite Medical Procedure Identifier S SV202-1 Product Service ID Qualifier R Use 'HC' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes. SV202-3 SV202-4 SV202-5 SV202-6 Procedure Modifier S SV205 Quantity S Use whole number unit values. DTP Date - Service Date R DTP02 Date Time Period Qualifier R Valid values: 'D8' Single Date (CCYYMMDD) 'RD8' Range of Dates Use 'RD8' to specify a range of dates. The from and thru service dates should be sent for each service line. Loop 2400 - Service Line Number 11 | /kaggle/input/edi-db-835-837/837 Health Care Claim Companion Guide Rev 12 2011.pdf | 85a8528b1eeb2fb3eeb424b143cdb49f | 85a8528b1eeb2fb3eeb424b143cdb49f_0 |
HIPAA Transaction Standard Companion Guide Healthcare Claim Payment Advice ASC X12N 835 Version 005010X221A1 for State of Idaho MMIS Date of Publication: 02 29 2024 Document Number: TL419 Version: 11.0 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page ii Revision History Version Date Author Action Summary of Changes 1.0 07 01 2011 Molina Initial document 1.1 09 09 2013 Molina Modified to conform to CAQH CORE standards 1.2 11 11 2013 Molina Updated with DHW requested changes 1.3 01 14 2014 Molina Changed the Data Flow Diagram in Section 4, and added information about Web Services in Section 4 2.0 01 31 2014 TQD DHW approved 1 27 2014 2.1 04 28 2014 J Phillips Added information about sending acknowledgements via Upload and VAN in Section 4 Connectivity with the Payer Communications Process Flows per CR 35250 3.0 05 14 2014 TQD DHW validated 5 5 2014 3.1 05 20 2015 M McFadden Semi-annual review performed made changes 3.2 05 26 2015 Hope McCain Removed references to retired TPA user guides. 4.0 06 15 2015 TQD DHW validated 6 10 2015 4.0 12 22 2015 D Greer Semi-annual review no changes 4.0 5 26 2016 J Phillips Semi-annual review no changes 4.1 12 19 2016 J Richardson Semi-annual review remove secured FTP information and replace with VAN 5.0 1 18 2017 TQD DHW validated 1 12 2017 5.1 6 7 2017 Douglas Greer Semi-annual review minor corrections 6.0 7 27 2017 TQD DHW validated changes 7 27 17 6.1 8 15 2017 Hope McCain Updated for TPA upgrade 6.2 11 22 2017 Hope McCain Additional updates based on State review 7.0 12 1 2017 TQD DHW validated changes 11 30 17 7.0 6 21 2018 J Richardson Semi-annual review no changes 7.1 10 5 2018 M Zampierin Removed Molina reference and replaced with DXC Technology 7.1 11 27 2018 Jimmy Phillips Semi-annual review no changes 7.1 3 1 2019 Jimmy Phillips Semi-annual review no changes 7.1 3 29 2019 Cathy Lavacchia Semi-annual review no changes 7.1 11 27 2019 Jimmy Phillips Semi-annual review no changes 7.2 03 10 2020 Cathy Lavacchia Changed for Rebranding CR 58031 8.0 03 30 2020 TQD Finalized per DHW validated changes. 8.0 4 22 2021 Douglas Greer Semi-annual review no changes 8.1 11 22 2021 Jen Richardson CMS semi-annual review, no content updates. Rebranding changes only. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page iii Version Date Author Action Summary of Changes 9.0 01 21 2022 TQD Finalized for publishing after rebranding 9.0 06 03 2022 Jimmy Phillips Reviewed for semi-annual; no updates necessary. 9.1 08 24 2022 Myranda Payne Clarified Register link location in section 2.2 Trading Partner Registration 10.0 09 30 2022 TQD Finalized per DHW validated changes. 10.0 11 23 2022 Jimmy Phillips Reviewed for semi-annual; no updates necessary. 10.1 05 24 2023 Kelsey Nielsen Changed the sentence "FTP though a secure, dedicated VAN connection." to "FTP through a secure, dedicated VAN connection." 10.2 11 16 2023 Kelsey Nielsen Semi-annual review; Grammatical corrections 10.3 01 25 2024 Jimmy Phillips Changed for Gainwell rebranding project CR 76444 11.0 02 29 2024 TQD Finalized per DHW validated changes. 2020-2024 Gainwell Technologies Company. All rights reserved. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page iv Table of Contents Introduction........................................................................................................ 1 1.1. Scope........................................................................................................... 2 1.2. Overview...................................................................................................... 2 1.3. References.................................................................................................... 2 1.4. Additional Information.................................................................................... 2 Getting Started.................................................................................................... 3 2.1. Working with Gainwell Technologies................................................................ 3 2.2. Trading Partner Registration............................................................................ 3 2.3. Certification and Testing Overview.................................................................... 3 Testing with the Payer.......................................................................................... 3 Connectivity with the Payer Communications Process Flows...................................... 3 4.1. Process Flows................................................................................................ 4 4.2. Transmission Administrative Procedures........................................................... 5 4.3. Re-Transmission Procedure............................................................................. 5 4.4. Communication Protocol Specifications............................................................. 5 4.5. Passwords..................................................................................................... 6 Contact Information............................................................................................. 6 5.1. Gainwell Technologies EDI Helpdesk and EDI Technical Assistance....................... 6 5.2. Provider Service Number................................................................................ 6 5.3. Applicable Websites E-mail.............................................................................. 7 Control Segments and Envelopes.............................................................................. 7 6.1. Delimiters..................................................................................................... 7 6.2. ISA-IEA........................................................................................................ 7 6.3. GS-GE.......................................................................................................... 7 6.4. ST-SE........................................................................................................... 7 Payer-Specific Business Rules and Limitations......................................................... 8 Acknowledgments and or Reports.......................................................................... 8 8.1. Report Inventory (Not Sent for 835 Transactions)............................................. 8 Trading Partner Agreements.................................................................................. 8 Transaction Specific Information......................................................................... 8 Appendices..................................................................................................... 22 Appendix A. Implementation Checklist..................................................................... 22 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 1 of 22 Introduction This section describes how the 5010 X12 Type 3 Technical Reports (TR3) adopted under HIPAA will be detailed using a table. The tables contain a row for each segment where Gainwell Technologies has something additional, over and above the information in the TR3. That information can: Limit the repeat of loops or segments Limit the length of a simple data element Specify a sub-set of the TR3s internal code listings Clarify the use of loops, segments, composite and simple data elements Specify any other information tied directly to a loop, segment, composite, or simple data element pertinent to trading electronically with Gainwell Technologies In addition to the row for each segment, one or more additional rows are used to describe Gainwell Technologies' usage for composite and simple data elements and any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. Page Loop ID Referenc e Name Codes Length Notes Comments 193 2100C NM1 Subscriber Name This row type always indicates that a new segment has begun. It is always shaded at 10, and notes or comments about the segment go in this cell. 195 2100C NM109 Subscriber Primary Identifier 15 This row type exists to limit the length of the specified data element. 196 2100C REF Subscriber Additional 197 2100C REF01 Reference Identification Qualifier 18, 49, 6P, These are the only codes transmitted by Gainwell MS Healthcare. Plan Network Identification Number N6 This row type exists when a note for a particular code value is required. For example, this note may say that value N6 is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it. 218 2110C EB Subscriber Eligibility or Benefit 231 2110C EB13-1 Product Service ID Qualifier AD This row illustrates how to indicate a component data element in the Reference column and specify that only one code value is applicable. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 2 of 22 1.1. Scope This companion guide documents the transaction type listed below and further defines situational and required data elements for processing the 835 healthcare claim payment advice for programs administered by Idaho Medicaid. This document is not the complete EDI transaction format specifications. The complete EDI 835 transaction format can be found in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment Advice (835), as noted in the References section below. Healthcare Claim Payment Advice ASC X12N 835 (005010X221) Addenda Healthcare Claim Payment Advice ASC X12N 835 (005010X221A1) 1.2. Overview Data elements, segments, and loops not included in this guide are not used for processing transactions by Idaho Medicaid but will still be sent if the information is required for compliance with the ASC X12N version 5010A1 format. See the References section below. 1.3. References Please refer to the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment Advice (835) for information not supplied in this document, such as code lists, definitions, and edits. This TR3 Guide can be obtained from the Washington Publishing Company. Their website is https: www.wpc-edi.com. 1.4. Additional Information The CCD and X12 835 TR3 TRN Segment were adopted together as the Federal Healthcare EFT Standards in CMS-0024-IFC: Administrative Simplification: Adoption of Standards for Health Care Electronic Funds Transfers (EFTs) and Remittance Advice. The 835 Healthcare Claim Payment Advice allows automated matchup of claims payment data sent to the Receiver from Idaho Medicaid using computer software. The delivery and use of the 835 Healthcare Claim Payment continues to increase compliance with HIPAA-adopted administrative transactions and encourages entities to use this infrastructure eligibility and claim status. Adoption of the 835 Healthcare Claim Payment Advice simplifies and standardizes information to match the payment to the remittance advice detail, thereby decreasing confusion around electronic funds transfer (EFT) and ERA. Consistent and uniform rules enable providers to match and process both the EFT payment and the v5010 X12 835 and help mitigate: o Unnecessary manual provider follow-up o Faulty electronic secondary billing o Inappropriate write-offs of billable charges o Incorrect billing of patients for co-pays and deductibles o Posting delays And provide for: o Less staff time spent on phone calls and websites o Increased ability to conduct targeted follow-up with health plans and or patients o More accurate and efficient payment of claims If you do not already receive the 835 Healthcare Claim Payment Advice (electronically), please contact the EDI Help Desk today at 1 (866) 686-4272 and select option 2 when prompted for more information. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 3 of 22 Getting Started 2.1. Working with Gainwell Technologies Please visit https: www.idmedicaid.com and click on the Companion Guides link under Reference Material to view the latest versions of this and other X12 Companion Guides. For information on how to use the portal once registered as a trading partner, click the User Guides link under Reference Material. For any questions or to begin testing, contact the Gainwell Technologies EDI Helpdesk at 1 (866) 686-4272 option 2, or e-mail us at idedisupport gainwelltechnologies.com. 2.2. Trading Partner Registration A Trading Partner Account (TPA) is any entity with which Gainwell Technologies exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Gainwell Technologies will assign trading partner IDs to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. To become a trading partner and get your trading partner ID, please visit our website at https: www.idmedicaid.com and click the Register link in the upper right-hand corner of the screen. You may also contact us at 1 (866) 686-4272, option 2. 2.3. Certification and Testing Overview All TPA must be authorized to submit production EDI transactions. Authorization is granted on a per-transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. Any TPA may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Testing with the Payer Trading partners must submit three test files of a particular transaction type, with a minimum of fifteen transactions within each file, and have no failures or rejections to become certified for production. Users will be notified via e-mail and the Trading Partner Status page of the Health PAS website when testing for a particular transaction has been completed. The Trading Partner Status page is found by logging into your trading partner account on the Health PAS website (https: www.idmedicaid.com), hovering over the Account Management tab, and then clicking User Status. Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be found on the Health PAS website under Companion Guides in the 5010 Appendix A Vendor Specs document. Connectivity with the Payer Communications Process Flows Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 4 of 22 4.1. Process Flows Below is the TPA Portal Services Process Flow (Retrieval of an 835 using the TPA Portal Services). Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 5 of 22 Below is the CAQH Web Services Process Flow (Generic Batch Retrieval Request of an 835). 4.2. Transmission Administrative Procedures X12 files (including an acknowledgment of an 835) can be uploaded via the Health PAS website File Exchange X12 Upload. 835 Healthcare Claim Payment Advice transaction files, acknowledgments, and responses to transactions submitted via the Health PAS website can be accessed by selecting Responses under the File Exchange menu. Trading Partners who have established a VAN connection and submitted X12 transactions via the VAN connection may retrieve acknowledgments and responses from their designated VAN Pickup locations. A VAN connection is a secure VPN connection through which X12 files are transferred via the FTP protocol. 4.3. Re-Transmission Procedure ISA13 Interchange Control Number needs to be unique to each file and Trading Partner ID. 4.4. Communication Protocol Specifications The following communications protocols are available for receiving the ASC X12N 835 transaction Files. Batch Mode: HTTPS download via the Health PAS website FTP through a secure, dedicated VAN connection CAQH Web Service: Authorized trading partners can request 835 transactions through CAQH Web Services. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 6 of 22 CAQH Phase III requires that a 999 be returned to the issuer of the 835 to acknowledge receipt and, if appropriate, report errors encountered with the 835 data1. The Gainwell Technologies CAQH Web Services have been enhanced to support this functionality. The CAQH Web Services support two types of transaction protocols: SOAP (Simple Object Access Protocol) and MIME (Multipurpose Internet Mail Extensions). Transactions can be sent through the following links: SOAP Transactions: https: www.idmedicaid.com CAQH_SOAPService SOAPService.svc MIME Transactions: https: www.idmedicaid.com CAQH_MIMEService MIMEService.svc When requesting an 835 using the CAQH Web Services: The PayloadID needs to be set to the Check EFT Payment ID for the desired 835 The PayloadType needs to be specified as X12_835_Request_005010X221A1 The ProcessingMode needs to be set to Batch The requesting Trading Partner ID must match the Receiver ID of the 835 transaction requested When sending a 999 response using the CAQH Web Services: Set the 999 AK102 to the value of the GS06 value for the 835 that the 999 is in response to The PayloadType should be set to X12_999_SubmissionRequest_005010X231A1 The ProcessingMode needs to be set to Batch The following Operations and Messages are supported: Operation Request Response GenericBatchRetrievalRequest GenericBatchRetrievalRequestMessage GenericBatchRetrievalResp onseMessage PayloadReceiptConfirmation PayloadReceiptConfirmationRequestMes sage PayloadReceiptConfirmatio nResponseMessage 4.5. Passwords Trading Partners create their passwords at the time of registration and are required to update them every 60 days per the Health PAS-Online requirements. The password must be at least seven (7) characters long, contain at least one (1) uppercase character, at least one (1) numeral, and at least one (1) special character (!). Contact Information This section contains detailed information concerning EDI Customer Service. 5.1. Gainwell Technologies EDI Helpdesk and EDI Technical Assistance 1 (866) 686-4272 option 2, or e-mail idedisupport gainwelltechnologies.com. 5.2. Provider Service Number 1 (866) 686-4272 option 3, or e-mail idproviderservices gainwelltechnologies.com. 1 Note CAQH has ruled that it is not mandatory for the receiver of an 835 to send a 999. If a 999 is sent, however, the system will accept it for processing. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 7 of 22 5.3. Applicable Websites E-mail The Idaho Medicaid Health PAS website contains companion guides, user guides, and other information needed to download the 835 Healthcare Claim Payment Advice transaction files. Website https: www.idmedicaid.com The e-mail addresses below can be used to contact Idaho Medicaid s EDI Support, Provider Services, and Provider Enrollment departments. These groups can assist and answer questions relating to EDI file submissions, provider enrollment, and services. EDI Support idedisupport gainwelltechnologies.com Provider Services idproviderservices gainwelltechnologies.com Provider Enrollment idproviderenrollment gainwelltechnologies.com Control Segments and Envelopes 6.1. Delimiters Idaho Medicaid does not require specific values for the delimiters used in electronic transactions. The suggested values are included in the specifications below. 6.2. ISA-IEA The following ISA IEA fields are the sender and receiver specific information listed in the 835 transactions. For all other fields, please see the tables below. ISA06 Interchange Sender ID will contain ID_MES_4_MMS_IG ISA08 Interchange Receiver ID will contain the Gainwell Technologies assigned trading partner ID ISA13 Sender generated Interchange Control Number. This number will match the number in IEA02 Please refer to the tables below for the ISA-IEA-specific information for the 835. 6.3. GS-GE The following GS GE fields are the sender and receiver-specific information listed in the 835 transactions. For all other fields, please see the tables below. GS02 Interchange Sender ID will contain ID_MES_4_MMS_IG GS03 Interchange Receiver ID will contain the Gainwell Technologies assigned trading partner ID GS06 Sender generated Group Control Number. Will match the number in GE02 Please refer to the tables below for the GS-GE-specific information for the 835 transactions. 6.4. ST-SE ST02 Sender generated Transaction Set Control Number. Must match the number in SE02 Please refer to the tables below for the ST-SE-specific information for the 835 transactions. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 8 of 22 Payer-Specific Business Rules and Limitations For Gainwell Technologies Healthcare-specific business rules and limitations associated with the ASC X12N 835 Healthcare Claim Payment Advice transaction, please refer to the tables under Section 10 below. Acknowledgments and or Reports The 835 Healthcare Claim Payment Advice transaction files are generated weekly and advise report on claims that are in their finalized status (paid, denied, reversed, etc.). Once generated, the 835 file(s) can be downloaded via the trading partner s site. The following acknowledgments reports related to the submission of EDI transactions by a trading partner are not sent out for 835 transactions. 8.1. Report Inventory (Not Sent for 835 Transactions) TA1 Interchange Acknowledgment. This acknowledgment is sent if requested by setting ISA14 to 1 or if ISA14 is set to 0 and there is an error that needs to be reported 999 Functional Acknowledgment. This acknowledgment file reports any errors found while checking compliance against TR3 specifications or acceptance of an EDI transaction that meets the TR3 specifications 824 Application Advice report This transaction is not mandated by HIPAA, but will be used to report the results of data content edits of transaction sets. It is designed to report rejections based on business rules, such as invalid diagnosis codes, invalid procedure codes, and invalid provider numbers. The 824 Application Advice report does not replace the 999 or TA1 transactions and will only be generated by Health PAS if there are errors within the transaction set BRR Business Rejection Report. Health PAS also produces a readable version of the 824 called the Business Rejection Report (BRR). This report helps to facilitate the immediate correction and re-bill of claims rejected during HIPAA validation Trading Partner Agreements A trading partner agreement is comprised of the completion of the trading partner registration activities and the approval to submit or receive specific transactions. Please refer to Section 2, sub-section Trading Partner Registration, for information on how to register as a trading partner and be authorized to send receive EDI transactions. Transaction Specific Information Listed below in Figure 10-1 are the specific requirements for reading and processing an ASC X12N 835 Healthcare Claim Payment Advice transaction file returned by Gainwell Technologies. Please use these guidelines in conjunction with the official ASC X12N 835 TR3 document to read and process the downloaded 835 Healthcare Claim Payment Advice transaction files. Figure 10-1: 835 Healthcare Claim Payment Advice Page Loop ID Reference Name Codes Length Notes Comments C.3 HEAD ER ISA Interchange Control Header ISA 3 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 9 of 22 Page Loop ID Reference Name Codes Length Notes Comments C.4 ISA01 Authorization Information Qualifier 00 2 Element Separator 1 ISA02 Authorization Information Space Fill 10 Element Separator 1 ISA03 Security Information Qualifier 00 2 Element Separator 1 ISA04 Security Information Not Used - Filled with Spaces 10 Element Separator 1 ISA05 Interchange ID Qualifier ZZ 2 Element Separator 1 ISA06 Interchange Sender ID ID_MES_4_MMS_I G or ID_MMIS_4MOLINA or ID_MMIS_4_DXCM S 15 Element Separator 1 C.5 ISA07 Interchange ID Qualifier ZZ - Mutually Defined 2 Element Separator 1 ISA08 Interchange Receiver ID Gainwell MS assigned Trading Partner ID 15 Gainwell MS assigned at registration C.5 Element Separator 1 ISA09 Interchange Date YYMMDD 6 Element Separator 1 ISA10 Interchange Time HHMM 4 Element Separator 1 ISA11 Repetition Separator 1 Element Separator 1 ISA12 Interchange Version Number 00501 5 Element Separator 1 ISA13 Interchange Control Number Assigned by Sender 9 (must be identical to interchange trailer IEA02) Element Separator 1 C.6 ISA14 Acknowledgment Requested 0 - No Ack. Requested 1 Element Separator 1 ISA15 Usage Indicator P 1 Element Separator 1 ISA16 Component Element Separator: 1 Segment End 1 C.7 GS Functional Group Header GS 2 Element Separator 1 GS01 Functional Identifier Code HP 2 C.7 Element Separator 1 GS02 Application Sender's Code Must be identical to the value in the ISA06 6 Element Separator 1 GS03 Application Receiver's Code Gainwell MS assigned Trading Partner ID 2 15 This is assigned during trading partner registration Element Separator 1 C.8 GS04 Date CCYYMMDD 8 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 10 of 22 Page Loop ID Reference Name Codes Length Notes Comments GS05 Time HHMM 4 8 Time based on a 24- hour clock Element Separator 1 GS06 Group Control Number (Assigned by Sender) Must be identical to the value in the GS02 1 9 Element Separator 1 GS07 Responsible Agency Code X 1 2 Element Separator 1 GS08 Version Release Code 005010X221A1 1 12 Segment End 1 68 ST Transaction Set Header ST 2 Element Separator 1 ST01 Transaction Set Identification Code 835 3 Element Separator 1 ST02 Transaction Set Control Number Sequential number assigned by sender ST02 and SE02 must be identical 4 9 Segment End 1 69 HEAD ER BPR Financial Information BPR 3 70 BPR01 Transaction Handling Code I remittance information only 1 2 Element Separator 1 71 BPR02 Monetary Amount 1 18 Payment amount Element Separator 1 BPR03 Credit Debit Flag code C Credit - payment to the receiver s account 1 Element Separator 1 72 BPR04 Payment Method Code CHK Check BOP Financial Institution Option 3 Payment Format Code 1 10 Element Separator 1 73 BPR06 (DFI)ID Number Qualifier 01 when BPR04 BOP 2 Element Separator 1 BPR07 (DFI) Identification Number 3 12 Required when BPR04 BOP Element Separator 1 74 BPR08 Account Number Qualifier DA - Demand Deposit when BPR04 BOP 1 3 Element Separator 1 BPR09 Account Number Required when BPR04 BOP Element Separator 1 BPR10 Originating Company Identifier 10 Required when BPR04 BOP Element Separator 1 Element Separator 1 75 BPR12 (DFI) ID Number Qualifier 01 - ABATransit Routing Number Including Check Digits when BPR04 BOP 2 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 11 of 22 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 BPR13 (DFI) Identification Number 3 12 Bank Number Element Separator 1 76 BPR14 Account Number Qualifier 1 3 Account Type Element Separator 1 BPR15 Account Number 1 35 Bank Account Number Element Separator 1 BPR16 Date CCYYMMDD 8 EFT or Check Issue Date Segment End 1 77 HEAD ER TRN Reassociation Trace Number TRN 3 Element Separator 1 TRN01 Trace Type Code 1 Current Transaction Trace Number 1 2 Element Separator 1 TRN02 Reference Identification 1 50 Check or EFT Trace Number Element Separator 1 TRN03 Originating Company Identifier 10 Payer Identifier Segment End 1 85 HEAD ER DTM Production Date DTM 3 Element Separator 1 DTM01 Date Time Qualifier 405 Production 3 Element Separator 1 86 DTM02 Date CCYYMMDD 8 Production Date Segment End 1 87 1000A N1 Payer Identification N1 2 Element Separator 1 N101 Entity Identifier Code PR Payer 2 3 Element Separator 1 N102 Name 1 60 Payer Name Segment End 1 89 1000A N3 Payer Address N3 2 Element Separator 1 N301 Address Information Payer Address 1 55 Payer Address Segment Terminator 1 90 1000A N4 Payer City, State, ZIP Code N4 2 Element Separator 1 N401 City Name 2 30 City Element Separator 1 91 N402 State or Province Code 2 State - Required if address is in the United States Element Separator 1 N403 Postal Code 3 15 Zip Code - Required if address is in the United States Segment Terminator 1 94 1000A PER Payer Business Contact Information PER 3 Element Separator 1 95 PER01 Contact Function Code CX Payers Claim Office 2 Element Separator 1 PER02 Name 1 60 Contact Name Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 12 of 22 Page Loop ID Reference Name Codes Length Notes Comments PER03 Communication Number Qualifier TE Telephone 2 Element Separator 1 PER04 Communication Number AAABBBCCCC 1 256 Contact Number Segment End 1 97 1000A PER Payer Technical Contact Information PER 3 Element Separator 1 PER01 Contact Function Code BL Technical Department 2 Element Separator 1 98 PER02 Name 1 60 Contact Name Element Separator 1 PER03 Communication Number Qualifier TE Telephone 2 Element Separator 1 PER04 Communication Number AAABBBCCCC 1 256 Contact Number Segment Terminator 1 102 1000B N1 Payee Identification N1 2 Element Separator 1 N101 Entity Identifier Code PE Payee 2 3 Element Separator 1 N102 Name 1 60 Provider Name Element Separator 1 103 N103 Identification Code Qualifier FI Federal Taxpayer s Identification Number XX Health Care Financing Administration National Provider ID 1 2 Element Separator 1 N104 Identification Code 2 80 Identification Code - NPI or Tax ID Segment Terminator 1 104 1000B N3 Payee Address N3 2 Element Separator 1 N301 Address Information 1 55 Payee Address Line 1 Street, PO Element Separator 1 N302 Address Information 1 55 Address Line 2 - Suite Segment Terminator 1 105 1000B N4 Payee City, State, ZIP Code N4 2 Element Separator 1 N401 City Name 2 30 City Element Separator 1 106 N402 State or Province Code 2 Required if address is in the United States Element Separator 1 N403 Postal Code 3 15 Required if address is in the United States Segment Terminator 1 107 1000B REF Payee Additional identification REF 3 Reference Identification Element Separator 1 REF01 Reference Identification Qualifier TJ SSN FEIN Qualifier, If N103 XX 2 3 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 13 of 22 Page Loop ID Reference Name Codes Length Notes Comments PQ Payee Identification Molina Element Separator 1 108 REF02 Reference Identification 1 50 SSN FEIN (Tax ID) if REF01(1) TJ Segment Terminator 1 111 2000 LX Header Number LX 2 Element Separator 1 LX01 Assigned Number 1 6 Sequential Number Segment Terminator 1 123 2100 CLP Claim Payment Information CLP 3 Claim Level Data CLP01 is from CLM01 of the original claim (generated by the provider) Element Separator 1 CLP01 Claim Submitter s Identifier 1 38 Provider Claim ID (also known as the Patient Control Number) Element Separator 1 124 CLP02 Claim Status Code 1 Paid Primary 2 Paid Secondary 3 Paid Tertiary 4 Denied 22 Reversal 1 2 Element Separator 1 125 CLP03 Monetary Amount 1 18 Billed Amount The billed amount for each claim Element Separator 1 125 CLP04 Monetary Amount 1 18 Paid Amount The dollar amount included in the payment for the claim Element Separator 1 CLP05 Monetary Amount 1 18 Co-Pay Amount Element Separator 1 126 CLP06 Claim Filing Indicator Code MC - Medicaid 1 2 Code Identifying the type of claim Element Separator 1 127 CLP07 Reference Identification 1 50 Claim Internal Control Number (ICN) Element Separator 1 CLP08 Facility Code Value 1 2 Place of Service. Facility Service Code and Claim Frequency Type Code come from CLM05-1 and -2 of 837 Claim Element Separator 1 CLP09 Claim Frequency Type Code 1 Claim Frequency Type Code. Facility Service Code and Claim Frequency Type Code come from CLM05-1 and -2 of 837 Claim Segment Terminator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 14 of 22 Page Loop ID Reference Name Codes Length Notes Comments 129 2100 CAS Claims Adjustment CAS 3 Claim Adjustment (see note at end of CAS segment) Element Separator 1 131 CAS01 Claim Adjustment Group Code CO Contractual Obligations OA Other Adjustments PI Payer Initiated Reduction PR Patient Responsibility 1 2 Element Separator 1 CAS02 Claim Adjustment Reason Code 1 5 First claim adjustment reason code Element Separator 1 132 CAS03 Monetary Amount 1 18 First claim adjustment amount Element Separator 1 Element Separator 1 CAS05 Claim Adjustment Reason Code 1 5 Second claim adjustment reason code Element Separator 1 133 CAS06 Monetary Amount 1 18 Second claim adjustment amount Element Separator 1 Element Separator 1 CAS08 Claim Adjustment Reason Code 1 5 Third claim adjustment reason code Element Separator 1 CAS09 Monetary Amount 1 18 Third claim adjustment amount Element Separator 1 134 Element Separator 1 CAS11 Claim Adjustment Reason Code 1 5 Fourth claim adjustment reason code Element Separator 1 CAS12 Monetary Amount 1 18 Fourth claim adjustment amount Element Separator 1 Element Separator 1 135 CAS14 Claim Adjustment Reason Code 1 5 Fifth claim adjustment reason code Element Separator 1 CAS15 Monetary Amount 1 18 Fifth claim adjustment amount Element Separator 1 Element Separator 1 CAS17 Claim Adjustment Reason Code 1 5 Sixth claim adjustment reason code Element Separator 1 136 CAS18 Monetary Amount 1 18 Sixth claim adjustment amount Segment Terminator 1 Note: Additional CAS segments (up to 99 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 15 of 22 Page Loop ID Reference Name Codes Length Notes Comments total) will be mapped if there are more than six (6) EOB codes passed. 137 2100 NM1 Patient Name NM1 3 Individual or Organizational Name Element Separator 1 NM101 Entity Identifier Code QC Patient Name 2 Element Separator 1 138 NM102 Entity Type Qualifier 1 Person 1 Element Separator 1 NM103 Name, Last or Organization Name 1 60 Client Last Name Required for all claims that are not retail pharmacy claims. Required for retail pharmacy claims when the information is known. Element Separator 1 NM104 Name, First 1 35 Client First Name Required when the patient has a first name, and it is known. Element Separator 1 NM105 Name, Middle 1 25 Client Middle Name Element Separator 1 Element Separator 1 NM107 Name, Suffix 1 10 Client Name Suffix Element Separator 1 139 NM108 Identification Code Qualifier MI Member Identification Number 1 2 Element Separator 1 NM109 Identification Code 2 80 Client Medicaid ID Number Segment Terminator 1 146 2100 NM1 Service Provider Name NM1 3 Element Separator 1 147 NM101 Entity Identifier Code 82 Rendering Provider 2 3 Element Separator 1 NM102 Entity Type Qualifier 1 Person 2 Non-Person 1 Element Separator 1 NM103 Name, Last or Organization Name 1 60 Rendering Provider Last Name Element Separator 1 NM104 Name, First 1 35 Rendering Provider First Name Element Separator 1 148 Element Separator 1 Element Separator 1 Element Separator 1 NM108 Identification code Qualifier XX National Provider ID MC Medicaid Provider Number 1 2 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 16 of 22 Page Loop ID Reference Name Codes Length Notes Comments 149 NM109 Identification Code 2 80 NPI or Provider ID Segment Terminator 1 Note: For TPL Claims: Information for up to three (3) Insurance Companies may be transmitted in N1 segments. If the insurance company name is not available, there will be no NM1 segments for the company. If both the company name and policyholder numbers are not available, neither NM1 segment will be mapped. 153 2100 NM1 Corrected Priority Payer Name NM1 3 Element Separator 1 NM101 Entity Identifier Code PR Payer 2 3 Element Separator 1 154 NM102 Entity Type Qualifier 2 Non-Person Entity 1 Element Separator 1 NM103 Name, Last or Organization Name 1 60 Corrected Priority Payer Name Element Separator 1 Element Separator 1 Element Separator 1 Element Separator 1 Element Separator 1 NM108 Identification code Qualifier PI Payer Identification 1 2 NM109 Identification Code 2 80 Payer Identification Number Segment Terminator 1 173 2100 DTM Statement From or To Date DTM 3 Claim Date Element Separator 1 174 DTM01 Date Time Qualifier 232 From Date of Service 233 To Date of Service 3 Element Separator 1 DTM02 Date CCYYMMDD 8 8 From Date of Service where DTM01 232 To Date of Service where DTM01 233 Segment Terminator 1 175 2100 DTM Coverage Expiration Date DTM 3 Element Separator 1 DTM01 Date Time Qualifier 036 Expiration 3 Element Separator 1 DTM02 Date CCYYMMDD 8 Segment Terminator 1 177 2100 DTM Claim Receive Date DTM 3 Element Separator 1 DTM01 Date Time Qualifier 050 - Received 3 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 17 of 22 Page Loop ID Reference Name Codes Length Notes Comments DTM02 Date CCYYMMDD 8 Segment Terminator 1 184 2100 QTY Claim Supplemental Information Quantity QTY 3 Quantity Gainwell MS uses this segment; ID does not Element Separator 1 QTY01 Quantity Qualifier 2 Element Separator 1 185 QTY02 Quantity 1 15 Segment Terminator 1 186 2110 SVC Service Payment Information SVC 3 187 SVC01-1 Product Service ID Qualifier AD American Dental Association Codes HC HCFA HCPCS Codes N4 National Drug code 5-4-2 format 2 Component Separator: 1 188 SVC01-2 Product Service ID 1 48 Product Service Drug code Component Separator: 1 SVC01-3 Procedure Modifier 2 Modifier-1 Component Separator: 1 189 SVC01-4 Procedure Modifier 2 Modifier-2 Component Separator: 1 SVC01-5 Procedure Modifier 2 Modifier-3 Component Separator: 1 SVC01-6 Procedure Modifier 2 Modifier-4 Element Separator 1 SVC02 Monetary Amount 1 18 Total Charges Billed Element Separator 1 190 SVC03 Monetary Amount 1 18 Provider Payment Amount Element Separator 1 SVC04 Product Service ID 1 48 Revenue Code Element Separator 1 SVC05 Quantity 1 15 Paid Quantity Element Separator 1 Element Separator 1 193 SVC07 Quantity 1 15 Quantity Billed - if different from SVC05 Segment Terminator 1 194 2110 DTM Service Date DTM 3 2110 Element Separator 1 195 DTM01 Date Time Qualifier 150 Service Period Start 151 Service Period End 472 Service (for single-day service) 3 Element Separator 1 DTM02 Date CCYYMMDD 8 Service Date Segment Terminator 1 196 2110 CAS Service Adjustment CAS 3 see note 3 below Element Separator 1 198 CAS01 Claim Adjustment Group Code CO Contractual Obligations OA Other Adjustments 1 2 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 18 of 22 Page Loop ID Reference Name Codes Length Notes Comments PR Patient Responsibility Element Separator 1 CAS02 Claim Adjustment Reason Code 1 5 First claim adjustment reason code Element Separator 1 199 CAS03 Monetary Amount 1 18 First claim adjustment amount Element Separator 1 Element Separator 1 CAS05 Claim Adjustment Reason Code 1 5 Second claim adjustment reason code Element Separator 1 CAS06 Monetary Amount 1 18 Second claim adjustment amount Element Separator 1 200 Element Separator 1 CAS08 Claim Adjustment Reason Code 1 5 Third claim adjustment reason code Element Separator 1 CAS09 Monetary Amount 1 18 Third claim adjustment amount Element Separator 1 Element Separator 1 201 CAS11 Claim Adjustment Reason Code 1 5 Fourth claim adjustment reason code Element Separator 1 CAS12 Monetary Amount 1 18 Fourth claim adjustment amount Element Separator 1 Element Separator 1 202 CAS14 Claim Adjustment Reason Code 1 5 Fifth claim adjustment reason code Element Separator 1 CAS15 Monetary Amount 1 18 Fifth claim adjustment amount Element Separator 1 Element Separator 1 203 CAS17 Claim Adjustment Reason Code 1 5 Sixth claim adjustment reason code Element Separator 1 CAS18 Monetary Amount 1 18 Sixth claim adjustment amount Segment Terminator 1 Note: At a minimum, the Claim Detail CAS segment will contain the Claim Adjustment Group Code (CAS01), Claim Adjustment Code 1 (CAS02), and Adjustment Amount (CAS03). No other fields will be transmitted if there is no data. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 19 of 22 Page Loop ID Reference Name Codes Length Notes Comments Note: A second CAS segment for the Claim Detail will be mapped if more than six (6) detail EOB codes are passed. 204 2110 REF Service Identification REF 3 Element Separator 1 REF01 Reference Identification Qualifier BB Authorization Number 2 3 Element Separator 1 205 REF02 Reference Identification 1 50 Trace Service Line Segment Terminator 1 206 2110 REF Line Item Control Number REF 3 Element Separator 1 REF01 Reference Identification Qualifier 6R Provider Control Number 2 3 Element Separator 1 REF02 Reference Identification 1 50 Line Item Control Number Segment Terminator 1 Note: Second REF segment for Rendering or Attending Provider Information exists and is populated with Medicaid Provider number only when the REF01 value in the previous REF segment is BB and its corresponding REF02 value is equal to a National Provider ID and when a Rendering or Attending Provider Number exists. 209 2110 REF Healthcare Policy Identification REF 3 Element Separator 1 210 REF01 Reference Identification Qualifier 0K Policy Form Identifying Number 2 3 Element Separator 1 REF02 Reference Identification 1 50 Healthcare Policy Identification Segment Terminator 1 211 2110 AMT Service Supplemental Amount AMT 3 Element Separator 1 AMT01 Amount Qualifier Code B6 Allowed Actual 1 3 Element Separator 1 212 AMT02 Monetary Amount 1 18 Amount Allowed Segment Terminator 1 215 2110 LQ Industry Code Health Care Remark Codes LQ 2 Element Separator 1 LQ01 Code List Qualifier Code HE Allowed Actual 1 3 Element Separator 1 216 LQ02 Industry Code 1 30 Remark Code Segment Terminator Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 20 of 22 Page Loop ID Reference Name Codes Length Notes Comments 217 Summ ary PLB Provider Adjustment PLB 3 Transaction Set Trailer Element Separator 1 218 PLB01 Reference Identification 1 50 Provider Number (If the Provider has an NPI, the NPI is used) Summ ary Element Separator 1 PLB02 Date CCYYMMDD 8 Last Day of Current Year Element Separator 1 219 PLB03-1 Adjustment Reason Code 2 Reason Code 1 Component Separator: 1 222 PLB03-2 Reference Identification 1 50 Reference Number 1 May be a Cash Control Number (CCN) or Internal Control Number (ICN) Element Separator 1 223 PLB04 Monetary Amount 1 18 Adjustment Amount 1 This field may also be NEGATIVE PAYMENT due to insufficient positive cash flow Element Separator 1 PLB05-1 Adjustment Reason Code 2 Reason Code 2 Component Separator: 1 PLB05-2 Reference Identification 1 50 Reference number 2 See Reference Number 1 Element Separator 1 224 PLB06 Monetary Amount 1 18 Adjustment Amount 2 See Adjustment Amount 1 Element Separator 1 PLB07-1 Adjustment Reason Code 2 Reason Code 3 Component Separator: 1 PLB07-2 Reference Identification 1 50 Reference number 3 See Reference Number 1 Element Separator 1 PLB08 Monetary Amount 1 18 Adjustment Amount 3 See Adjustment Amount 1 Element Separator 1 225 PLB09-1 Adjustment Reason Code 2 Reason Code 4 Component Separator: 1 PLB09-2 Reference Identification 1 50 Reference number 4 See Reference Number 1 Element Separator 1 PLB10 Monetary Amount 1 18 Adjustment Amount 4 See Adjustment Amount 1 Element Separator 1 PLB11-1 Adjustment Reason Code 2 Reason Code 5 Component Separator: 1 226 PLB11-2 Reference Identification 1 50 Reference number 5 See Reference Number 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 21 of 22 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 PLB12 Monetary Amount 1 18 Adjustment Amount 5 See Adjustment Amount 1 Summ ary Element Separator 1 PLB13-1 Adjustment Reason Code 2 Reason Code 6 Component Separator: 1 PLB13-2 Reference Identification 1 50 Reference number 6 See Reference Number 1 Element Separator 1 227 PLB14 Monetary Amount 1 18 Adjustment Amount 6 See Adjustment Amount 1 Segment Terminator 1 228 TRAIL ER SE Transaction Set Trailer SE 2 3 Element Separator 1 SE01 Number of Included Segments 1 10 Total number of ST through SE segments Element Separator 1 SE02 Transaction Set Control Number 4 9 Assigned by Sender Must be identical to the value in ST02 Segment Terminator 1 C.9 GE Functional Group Trailer GE 2 Element Separator 1 GE01 Number of Transaction Sets Included 1 1 6 Element Separator 1 GE02 Group Control Number 1 9 Assigned by Sender Must be identical to the value in GS06 Segment Terminator 1 C.10 IEA Interchange Control Trailer IEA 3 Element Separator 1 IEA01 Number of Included Functional Groups 1 1 5 Element Separator 1 IEA02 Interchange Control Number 9 Assigned by Sender - Pad Left with Zeros Must be identical to value ISA13 Segment Terminator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 22 of 22 Appendices Appendix A. Implementation Checklist The Trading Partner Account (TPA) User Guide contains information on how to select the correct trading partner entity type and answers some preliminary questions concerning trading partner registration. This guide can be found on the User Guides link under Reference Material on www.idmedicaid.com. | /kaggle/input/edi-db-835-837/CAQH 5010 835 Companion Guide.pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_0 |
Stedi maintains this guide based on public documentation from CGS Medicare. Contact CGS Medicare for official EDI specifications. To report any errors in this guide, please contact us. X12 837 Health Care Claim: Institutional (X223A3) X12 Release 5010 Revised November 17, 2023 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care 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 billing information, 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 to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and or payment of health care services within a specific health care insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such 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 a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care insurance industry segment. Delimiters Segment Element Component Repetition 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 1 285 View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional- x223a3 01H25JDXFJR748R6M871MGNNCJ POWERED BY Build EDI implementation guides at stedi.com 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 2 285 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0050 Transaction Set Header Max use 1 Required BHT 0100 Beginning of Hierarchical Transaction Max use 1 Required Submitter Name Loop NM1 0200 Submitter Name Max use 1 Required PER 0450 Submitter EDI Contact Information Max use 2 Required Receiver Name Loop NM1 0200 Receiver Name Max use 1 Required Detail Billing Provider Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PRV 0030 Billing Provider Specialty Information Max use 1 Optional Billing Provider Name Loop NM1 0150 Billing Provider Name Max use 1 Required N3 0250 Billing Provider Address Max use 1 Required N4 0300 Billing Provider City, State, ZIP Code Max use 1 Required REF 0350 Billing Provider Tax Identification Max use 1 Required PER 0400 Billing Provider Contact Information Max use 2 Optional Pay-to Address Name Loop NM1 0150 Pay-to Address Name Max use 1 Required N3 0250 Pay-to Address - ADDRESS Max use 1 Required N4 0300 Pay-To Address City, State, ZIP Code Max use 1 Required Subscriber Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 3 285 SBR 0050 Subscriber Information Max use 1 Required Subscriber Name Loop NM1 0150 Subscriber Name Max use 1 Required N3 0250 Subscriber Address Max use 1 Optional N4 0300 Subscriber City, State, ZIP Code Max use 1 Optional DMG 0320 Subscriber Demographic Information Max use 1 Optional REF 0350 Property and Casualty Claim Number Max use 1 Optional Payer Name Loop NM1 0150 Payer Name Max use 1 Required N3 0250 Payer Address Max use 1 Optional N4 0300 Payer City, State, ZIP Code Max use 1 Optional REF 0350 Billing Provider Secondary Identification Max use 1 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Admission Date Hour Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional DTP 1350 Discharge Hour Max use 1 Optional DTP 1350 Statement Dates Max use 1 Required CL1 1400 Institutional Claim Code Max use 1 Required PWK 1550 Claim Supplemental Information Max use 10 Optional AMT 1750 Patient Estimated Amount Due Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Auto Accident State Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 5 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 4 285 REF 1800 Peer Review Organization (PRO) Approval Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Billing Note Max use 1 Optional NTE 1900 Claim Note Max use 10 Optional CRC 2200 EPSDT Referral Max use 1 Optional HI 2310 Admitting Diagnosis Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Diagnosis Related Group (DRG) Information Max use 1 Optional HI 2310 External Cause of Injury Max use 1 Optional HI 2310 Occurrence Information Max use 2 Optional HI 2310 Occurrence Span Information Max use 2 Optional HI 2310 Other Diagnosis Information Max use 2 Optional HI 2310 Other Procedure Information Max use 2 Optional HI 2310 Patient's Reason For Visit Max use 1 Optional HI 2310 Principal Diagnosis Max use 1 Required HI 2310 Principal Procedure Information Max use 1 Optional HI 2310 Treatment Code Information Max use 2 Optional HI 2310 Value Information Max use 2 Optional HCP 2410 Claim Pricing Repricing Information Max use 1 Optional Attending Provider Name Loop NM1 2500 Attending Provider Name Max use 1 Required PRV 2550 Attending Provider Specialty Information Max use 1 Optional REF 2710 Attending Provider Secondary Identification Max use 4 Optional Operating Physician Name Loop 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 5 285 NM1 2500 Operating Physician Name Max use 1 Required REF 2710 Operating Physician Secondary Identification Max use 4 Optional Other Operating Physician Name Loop NM1 2500 Other Operating Physician Name Max use 1 Required REF 2710 Other Operating Physician Secondary Identification Max use 4 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MIA 3150 Inpatient Adjudication Information Max use 1 Optional MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 6 285 N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 2 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3500 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV2 3750 Institutional Service Line Max use 1 Required PWK 4200 Line Supplemental Information Max use 10 Optional DTP 4550 Date - Service Date Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Facility Tax Amount Max use 1 Optional AMT 4750 Service Tax Amount Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional HCP 4920 Line Pricing Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 7 285 REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Operating Physician Name Loop NM1 5000 Operating Physician Name Max use 1 Required REF 5250 Operating Physician Secondary Identification Max use 20 Optional Other Operating Physician Name Loop NM1 5000 Other Operating Physician Name Max use 1 Required REF 5250 Other Operating Physician Secondary Identification Max use 20 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 8 285 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250131 0655 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 9 285 Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 10 285 Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 11 285 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HC XXX XXXXXXX 20250130 2128 0000000 X 005010X 223A3 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HC Health Care Claim (837) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 12 285 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X223A3 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 13 285 Heading ST 0050 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 837 0001 005010X223A3 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). 837 Health Care Claim ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. ST-03 1705 Version, Release, or Industry Identifier String (AN) Required Reference assigned to identify Implementation Convention The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08. Usage notes This element must be populated with the guide identifier named in Section 1.2. This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time. 005010X223A3 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 14 285 BHT 0100 Heading BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT 0019 00 XXX 20250130 2237 CH Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. BHT-03 127 Originator Application Transaction Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 15 285 year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time Time (TM) Required HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim Identifier Identifier (ID) Required Code specifying the type of transaction CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 16 285 1000A Submitter Name Loop Max 1 Required Variants (all may be used) Receiver Name Loop NM1 0200 Heading Submitter Name Loop NM1 Submitter Name To supply the full name of an individual or organizational entity Usage notes The submitter is the entity responsible for the creation and formatting of this transaction. Example NM1 41 2 X X XXXX 46 XXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 41 Submitter NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Submitter Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Submitter First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Submitter Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 17 285 Medicare does not support the submission of foreign currency. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) Established by trading partner agreement NM1-09 67 Submitter Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes The MAC will reject an interchange (transmission) that is submitted with a submitter identification number that is not authorized for electronic claim submission. Submitter ID must match the value submitted in ISA06 and GS02. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 18 285 PER 0450 Heading Submitter Name Loop PER Submitter EDI Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER IC XXXXX EM XXXX EM X FX X If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Submitter Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 19 285 1000A Submitter Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 20 285 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop NM1 0200 Heading Receiver Name Loop NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1 40 2 XXX 46 XX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 40 Receiver NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Receiver Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 21 285 1000B Receiver Name Loop end Heading end The MAC will reject an interchange (transmission) that is not submitted with a valid Part A MAC code. Each individual MAC determines this identifier. Submitter ID must match the value submitted in ISA08 and GS03. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 22 285 Detail 2000A Billing Provider Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 1 20 1 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 23 285 PRV 0030 Detail Billing Provider Hierarchical Level Loop PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRV BI PXC XX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 24 285 2010AA Billing Provider Name Loop Max 1 Required Variants (all may be used) Pay-to Address Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop NM1 Billing Provider Name To supply the full name of an individual or organizational entity Usage notes Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID- 2010BB. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop. When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. Example NM1 85 2 XXXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 25 285 NM1-03 1035 Billing Provider Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Billing Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 26 285 N3 0250 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N3 Billing Provider Address To specify the location of the named party Usage notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3 X XXXX Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 27 285 N4 0300 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXX XX Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Billing Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Billing Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Billing Provider Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 28 285 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 29 285 REF 0350 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop REF Billing Provider Tax Identification To specify identifying information Usage notes This is the tax identification number (TIN) of the entity to be paid for the submitted services. Example REF EI X Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Billing Provider Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 30 285 PER 0400 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.; When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER IC XXX FX XXXXXX FX X EM XXXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Billing Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 31 285 2010AA Billing Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 32 285 2010AB Pay-to Address Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information. Example NM1 87 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 87 Pay-to Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 33 285 N3 0250 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop N3 Pay-to Address - ADDRESS To specify the location of the named party Example N3 XXXXXX XXXXXX Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 34 285 N4 0300 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop N4 Pay-To Address City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXXXXX XX Only one of Pay-to Address State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-to Address City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-to Address State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-to Address Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 35 285 2010AB Pay-to Address Name Loop end 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 36 285 2000B Subscriber Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 2 1 22 0 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 22 Subscriber HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 37 285 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 38 285 SBR 0050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBR P 18 XXXXXX XXX OF Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. P Primary S Secondary T Tertiary SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. Usage notes For Medicare, the subscriber is always the same as the patient. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 39 285 Code identifying type of claim Usage notes For Medicare, the subscriber is always the same as the patient. 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) Medicare Risk 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 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 40 285 2010BA Subscriber Name Loop Max 1 Required Variants (all may be used) Payer Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes 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. Example NM1 IL 1 XXXXXX XXX X XX | /kaggle/input/edi-db-835-837/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_0 |
Segment in This Hierarchical Structure. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 38 285 SBR 0050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBR P 18 XXXXXX XXX OF Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. P Primary S Secondary T Tertiary SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. Usage notes For Medicare, the subscriber is always the same as the patient. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 39 285 Code identifying type of claim Usage notes For Medicare, the subscriber is always the same as the patient. 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) Medicare Risk 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 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 40 285 2010BA Subscriber Name Loop Max 1 Required Variants (all may be used) Payer Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes 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. Example NM1 IL 1 XXXXXX XXX X XX MI XXXXX If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 41 285 The first position must be alphabetic (A-Z). NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes The MBI: must be 11 positions in the format of C A AN N A AN N A A N N where C represents a constrained numeric 1 thru 9, A represents alphabetic character A Z but excluding S, L, O, I, B, Z, N represents numeric 0 thru 9, and AN represents either A or N. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 42 285 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3 XXXXXX XXXXXX Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Subscriber Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 43 285 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop N4 Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4 XXXX XX XXXXXXXX XXX Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Subscriber State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 44 285 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 45 285 DMG 0320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop DMG Subscriber Demographic Information To supply demographic information Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example DMG D8 X F Max use 1 Optional DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Subscriber Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. Usage notes Must not be a future date. DMG-03 1068 Subscriber Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 46 285 2010BA Subscriber Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop REF Property and Casualty Claim Number To specify identifying information Usage notes This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. Example REF Y4 XXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 47 285 2010BB Payer Name Loop Max 1 Required Variants (all may be used) Subscriber Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop NM1 Payer Name To supply the full name of an individual or organizational entity Usage notes This is the destination payer. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator. Example NM1 PR 2 X PI XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 48 285 Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification NM1-09 67 Payer Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 49 285 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N3 Payer Address To specify the location of the named party Usage notes 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. Example N3 XXXX XXXXXX Max use 1 Optional N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 50 285 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XX XX XXXXX XX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 51 285 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 52 285 2010BB Payer Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop REF Billing Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU XXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Billing Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 53 285 2300 Claim Information Loop Max 100 Optional CLM 1300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. 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 hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLM XXX 0000 X A X A Y Y 4 Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is 20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 54 285 Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim. When Medicare is primary payer, CLM02 must equal the sum of all SV203 service line charge amounts. When Medicare is Secondary or Tertiary payer, Total Submitted Charges (CLM02) must equal the sum of all 2320 2430 CAS amounts and the 2320 AMT02 (AMT01 D ). CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. A Uniform Billing Claim Form Bill Type C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and or has a participation agreement with the destination payer. OR 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 55 285 Required when the provider does not accept assignment and or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed Usage notes Data submitted in CLM20 will not be used for processing 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 56 285 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 Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 57 285 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Admission Date Hour To specify any or all of a date, a time, or a time period Usage notes Required on inpatient claims. If not required by this implementation guide, do not send. Example DTP 435 D8 XXX Variants (all may be used) DTP Date - Repricer Received Date DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes Selection of the appropriate qualifier is designated by the NUBC Billing Manual. Must not be a future date. D8 Date Expressed in Format CCYYMMDD DT Date and Time Expressed in Format CCYYMMDDHHMM DTP-03 1251 Admission Date and Hour Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage notes Must be in format HHMM.MM 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 58 285 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP 050 D8 XXXXXX Variants (all may be used) DTP Admission Date Hour DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 59 285 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Discharge Hour To specify any or all of a date, a time, or a time period Usage notes Required on all final inpatient claims. If not required by this implementation guide, do not send. Example DTP 096 TM XXXXXX Variants (all may be used) DTP Admission Date Hour DTP Date - Repricer Received Date DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. TM Time Expressed in Format HHMM DTP-03 1251 Discharge Time Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 60 285 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Statement Dates To specify any or all of a date, a time, or a time period Example DTP 434 RD8 XXXXX Variants (all may be used) DTP Admission Date Hour DTP Date - Repricer Received Date DTP Discharge Hour Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 434 Statement DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same. DTP-03 1251 Statement From and To Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 61 285 CL1 1400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CL1 Institutional Claim Code To supply information specific to hospital claims Example CL1 X X XX Max use 1 Required CL1-01 1315 Admission Type Code Min 1 Max 1 Identifier (ID) Required Code indicating the priority of this admission CL1-02 1314 Admission Source Code Min 1 Max 1 Identifier (ID) Optional Code indicating the source of this admission CL1-03 1352 Patient Status Code Min 1 Max 2 Identifier (ID) Required Code indicating patient status as of the "statement covers through date" 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 62 285 PWK 1550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Only the first iteration of the PWK, at either the claim level and or line level, will be considered in the claim adjudication. Example PWK A4 BM AC XX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 63 285 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. FT File Transfer Required when the actual attachment is maintained by an attachment warehouse or similar vendor. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 64 285 FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 65 285 AMT 1750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop AMT Patient Estimated Amount Due To indicate the total monetary amount Usage notes Required when the Patient Responsibility Amount is applicable to this claim. If not required by this implementation guide, do not send. Example AMT F3 00000000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F3 Patient Responsibility - Estimated AMT-02 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 66 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF 9C XXXXXX Variants (all may be used) REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 67 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Auto Accident State To specify identifying information Usage notes Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub- country code named in code source 22. If not required by this implementation guide, do not send. Example REF LU X Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LU Location Number REF-02 127 Auto Accident State or Province Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Values in this field must be valid codes found in code source 22. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 68 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REF D9 X Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 69 285 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 70 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF P4 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 71 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REF LX XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 72 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REF EA XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 73 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF F8 XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 74 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Peer Review Organization (PRO) Approval Number To specify identifying information Usage notes Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send. Example REF G4 X Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G4 Peer Review Organization (PRO) Approval Number REF-02 127 Peer Review Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 75 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF G1 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 76 285 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 77 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF 9F XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 78 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Repriced Claim Number To specify identifying information Usage notes This information is specific to the destination payer reported | /kaggle/input/edi-db-835-837/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_1 |
in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF G1 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 76 285 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 77 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF 9F XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 78 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Repriced Claim Number To specify identifying information Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example REF 9A XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 79 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF 4N XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Allowable values for this element are: 1 Immediate Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 80 285 6 Request for Override Pending 7 Special Handling 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 81 285 K3 1850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop K3 File Information To transmit a fixed-format record or matrix contents Usage notes 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. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3 X Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 82 285 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop NTE Billing Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Example NTE ADD XXXXXX Variants (all may be used) NTE Claim Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information NTE-02 352 Billing Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 83 285 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. OR Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services. If not required by this implementation guide, do not send. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTE RLH XXXXX Variants (all may be used) NTE Billing Note Max use 10 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ALG Allergies DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description DME Durable Medical Equipment (DME) and Supplies 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 Information NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 84 285 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC EPSDT Referral To supply information on conditions Usage notes Required on Early Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRC ZZ Y NU XXX XX Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 85 285 ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 86 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Admitting Diagnosis To supply information related to the delivery of health care Usage notes Required when claim involves an inpatient admission. If not required by this implementation guide, do not send.; Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BJ XXXX Variants (all may be used) HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABJ International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BJ International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis C022-02 1271 Admitting Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 87 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 88 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Condition Information To supply information related to the delivery of health care Usage notes Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BG XXXXX BG XXXXX BG XXXXXX BG XXX BG XX B G X BG XXXX BG XXXXX BG XX BG XXXXXX BG XXXX BG X XXXX Variants (all may be used) HI Admitting Diagnosis HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 89 285 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 90 285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 91 285 BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 92 285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 93 285 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 94 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Diagnosis Related Group (DRG) Information To supply information related to the delivery of health care Usage notes Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send. Example HI DR XXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. DR Diagnosis Related Group (DRG) C022-02 1271 Diagnosis Related Group (DRG) Code String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 95 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI External Cause of Injury To supply information related to the delivery of health care Usage notes 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. Do not transmit the decimal point for ICD codes. The decimal point is implied. In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes. Example HI ABN X N ABN XXXXXX Y BN X N BN XXXXXX U BN X W BN XXX W BN XXXX N BN XXX U BN XXXXX U ABN XXX N BN X N ABN XXXXXX U Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 96 285 the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 97 285 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 98 285 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 99 285 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 100 285 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 101 285 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 102 285 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 103 285 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 104 285 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 105 285 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission | /kaggle/input/edi-db-835-837/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_2 |
law, OR For claims which are not covered under HIPAA. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 104 285 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 105 285 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 106 285 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 107 285 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 108 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Occurrence Information To supply information related to the delivery of health care Usage notes Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BH XXXXX D8 XXXX BH XXXXXX D8 XXXXXX BH XXXX X D8 XXXXX BH X D8 XXXXXX BH XXXXXX D8 XX BH XX D 8 X BH XXXXX D8 XXX BH XXXXX D8 XXXX BH XXX D8 XX X BH XX D8 XXXXXX BH XXXXXX D8 X BH XXXXXX D8 XX X Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 109 285 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 110 285 Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 111 285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 112 285 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 113 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 114 285 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 115 285 BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 116 285 C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 117 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Occurrence Span Information To supply information related to the delivery of health care Usage notes Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BI XXXXX RD8 XX BI XXXXX RD8 XX BI XXXX RD8 XX X BI XXXX RD8 XXXXX BI XX RD8 XXXXXX BI X RD8 XX X BI XX RD8 XXXX BI XXXX RD8 XXX BI XXX RD8 XXXXX X BI XX RD8 XXXXXX BI XXX RD8 XXX BI XX RD8 XX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 118 285 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 119 285 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 120 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 121 285 Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 122 285 BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 123 285 C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 124 285 C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 125 285 RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 126 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Other Diagnosis Information To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. If not required by this implementation guide, do not send. Example HI ABF XXXX W BF XXXX Y BF XXX W BF XX N ABF X W BF XX U BF X XX N ABF XXX U BF XXXX W BF XXX XX Y ABF XXXXX N ABF XXXX W Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 127 285 BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 128 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 129 285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 130 285 Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a | /kaggle/input/edi-db-835-837/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_3 |
diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 130 285 Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 131 285 an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 132 285 C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 133 285 N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 134 285 Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 135 285 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 136 285 Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 137 285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 138 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Other Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BBQ XXXXXX D8 X BBQ XXX D8 XXXX BBQ XXX D8 XXX XXX BQ XXXXX D8 XXXX BQ XXXXX D8 XXXX BQ XXXXXX D 8 XXXXXX BBQ XXXX D8 XXX BQ XX D8 XXX BBQ XXXX D 8 XXXX BBQ XX D8 XXXXX BBQ XXXXX D8 XXXXX BBQ XX X D8 XXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 139 285 OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 140 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 141 285 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 142 285 Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 143 285 Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 144 285 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 145 285 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 146 285 C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 147 285 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 148 285 Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 149 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Patient's Reason For Visit To supply information related to the delivery of health care Usage notes Required when claim involves outpatient visits. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI PR XXXXX APR XXX APR XX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 150 285 APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 151 285 HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 152 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Principal Diagnosis To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BK XXXXX N Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Principal Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 153 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 154 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Principal Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI CAH XXXX D8 | /kaggle/input/edi-db-835-837/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_4 |
Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Principal Diagnosis To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BK XXXXX N Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Principal Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 153 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 154 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Principal Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI CAH XXXX D8 XXXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 155 285 BBR International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BR International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes CAH Advanced Billing Concepts (ABC) Codes C022-02 1271 Principal Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Principal Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 156 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Treatment Code Information To supply information related to the delivery of health care Usage notes Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. If not required by this implementation guide, do not send. Example HI TC X TC X TC XX TC XX TC XX TC XX TC X TC XXXX X TC X TC XXXXX TC XX TC XX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 157 285 Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 158 285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 159 285 TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 160 285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 161 285 Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 162 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Value Information To supply information related to the delivery of health care Usage notes Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BE XXX 0000000000 BE XX 0000 BE XXXXXX 0 00000000000000 BE XXXXX 000 BE XX 00000000000 000 BE XXXX 0 BE XXXXX 000000000000 BE XXXX 000000 BE XXXXX 000000 BE XXX 0000 BE X 00 000 BE XX 00000 Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 163 285 C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 164 285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 165 285 C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 166 285 BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 167 285 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 168 285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 169 285 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 170 285 HCP 2410 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HCP Claim Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 11 000000000000000 00000000000000 XXXXX 00000 0000 XX 0 XXX UN 00 T4 5 1 If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 171 285 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved DRG Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 172 285 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Repriced Approved Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 173 285 This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 174 285 2310A Attending Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop NM1 Attending Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send. The Attending Provider is the individual who has overall responsibility for the patient's medical care and treatment reported in this claim. Example NM1 71 1 XXXXX XXX XXX XXXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Attending Provider Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 71 Attending Physician When used, the term physician is any type of provider filling this role. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Attending Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Attending Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 175 285 Individual first name NM1-05 1037 Attending Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Attending Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Attending Provider Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 176 285 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop PRV Attending Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send. Example PRV AT PXC XXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AT Attending PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 177 285 2310A Attending Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop REF Attending Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 1G XX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Attending Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 178 285 2310B Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Operating Physician Name Loop NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 72 1 XXXX XXXXX XXXXXX XX XX XXXXX If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 179 285 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 180 285 2310B Operating Physician Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Operating Physician Name Loop REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 1G XXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 181 285 2310C Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Operating Physician Name Loop NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved. If not required by the implementation guide, do not send. The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician. This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 ZZ 1 XXXX XXXXX XX XX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 182 285 Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 183 285 2310C Other Operating Physician Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Operating Physician Name Loop REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF G2 XX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 184 285 2310D Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 82 1 XXXXXX XXX X XXXXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 185 285 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 186 285 2310D Rendering Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this | /kaggle/input/edi-db-835-837/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_5 |
Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 82 1 XXXXXX XXX X XXXXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 185 285 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 186 285 2310D Rendering Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU XXXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 187 285 2310E Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Example NM1 77 2 XXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 188 285 Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 189 285 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XX XXXXXX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 190 285 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXX XXX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 191 285 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 192 285 2310E Service Facility Location Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF LU XXX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 193 285 2310F Referring Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 DN 1 XXXXX XXXXXX XX XXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 194 285 2310F Referring Provider Name Loop end Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 195 285 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR F 18 XXXXXX XXXXX 14 Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. The SBR must contain a different value in each iteration of the SBR01. Each value may only be used one time per claim. 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 This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 196 285 Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 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) Medicare Risk 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 MC Medicaid OF Other Federal Program 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 197 285 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 198 285 CAS 2950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). CAS segment must not be present when 2000B SBR01 P Example CAS CR XXX 000000000000000 000000000000000 XXX X 0 0000000000 XXXX 0 0000000000000 XXX 0000 0 X X 00000000 000000000 XXXXX 0000000 000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 199 285 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 200 285 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 201 285 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 202 285 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT D 0000000 Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount Usage notes Medicare requires that one occurrence of 2320 loop with an AMT segment where AMT01 D must be present when 2000B SBR01 S. D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 203 285 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT A8 000000000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 204 285 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000000000000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 205 285 OI 3100 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI N Y Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 206 285 MIA 3150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes Required when inpatient adjudication information is reported in the remittance advice. OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MIA 000000000 000000000000000 00000000000 XXX 00 000 0000000000 000000000000 00000000000000 000000 0 0000 000000000 000000000 00000000000000 00 0000 000000000 00000000 0000000 0000000000000 X XXXX X XXXX XX 000000000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 207 285 MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 208 285 MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 209 285 MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 210 285 MOA 3200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA 0000 0000 XXXX XXX X XXXX XXXXXX 000000000000 00 0000000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 211 285 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 212 285 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 IL 1 XXXX X XXX XXXXX MI XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 213 285 Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 214 285 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3 XXX XXXXX Max use 1 Optional N3-01 166 Other Insured Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 215 285 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4 XXXXX XX XXXXX XX Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Insured City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Insured State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Insured Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 216 285 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 217 285 2330A Other Subscriber Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY XXXXX Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 9 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Must be 9 digits with no punctuation. First 3 digits cannot be higher than 272. Digits 1-3, 4-5, and 6-9 cannot be zeros. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 218 285 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 PR 2 XX XV XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 219 285 segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 220 285 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N3 Other Payer Address To specify the location of the named party Usage notes 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. Example N3 XXXXX XX Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 221 285 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XXXXX XX XXXX XXX Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) | /kaggle/input/edi-db-835-837/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_6 |
01H25JDXFJR748R6M871MGNNCJ 219 285 segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 220 285 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N3 Other Payer Address To specify the location of the named party Usage notes 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. Example N3 XXXXX XX Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 221 285 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XXXXX XX XXXX XXX Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 222 285 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 223 285 DTP 3500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP 573 D8 XXXXXX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage notes Must not be future date. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 224 285 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REF T4 XXXXX Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Only allowed value is "Y". 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 225 285 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REF F8 X Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only. REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 226 285 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REF G1 XXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 227 285 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF 9F XXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 228 285 2330B Other Payer Name Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF FY XXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 229 285 2400 Service Line Number Loop Max 999 Required LX 3650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX 0 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set Usage notes LX01 must be greater than zero and less than or equal to 449. An individual claim with service lines greater than 449 will be rejected (However, the transmission of claims will be accepted, per HIPAA). 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 230 285 SV2 3750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV2 Institutional Service Line To specify the service line item detail for a health care institution Example SV2 XXXX HC X XX XX XX XX XXXXXX 0000 UN 0 00000 0 Max use 1 Required SV2-01 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SV201 is the revenue code. Usage notes See Code Source 132: National Uniform Billing Committee (NUBC) Codes. SV2-02 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Usage notes Required for outpatient claims when an appropriate procedure code exists for this service line item. OR Required for inpatient claims when an appropriate HCPCS (drugs and or biologics only) or HIPPS code exists for this service line item. If not required by this implementation guide, do not send.; Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes If A0427, A0428 (with a QL modifier in SV202-3, SV202-4, SV202-5, or SV202-6), A0425, A0429, A0430, A0431, A0432, A0433, A0434, A0435, 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 231 285 A0488, or A0436 (nonscheduled transportation claim) are the only codes present, 2310A NM1 must not be preset. Otherwise, 2310A NM1 must be present. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV2-03 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV203 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 232 285 SV203 must be greater than zero. SV203 s decimal positions are limited to 0, 1, or 2. SV2-04 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit SV2-05 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV205 must be greater than zero and less than or equal to 999,999.9. Must be 0 or 1 decimal position. SV2-07 782 Line Item Denied Charge or Non-Covered Charge Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 233 285 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK 10 FX AC XXXXXXX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 234 285 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 235 285 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 236 285 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes Required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day. OR Required on service lines where a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written. If not required by this implementation guide, do not send. In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and 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 first day of the drug used by the patient is 1 1 00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was 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 supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1 1 00. In cases where a drug is being billed on a service line, a single date may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written). Example DTP 472 D8 XX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 237 285 Usage notes Must not be a future date, except for type of bill 0322 after 1 1 2021 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 238 285 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9D XXX Variants (all may be used) REF Line Item Control Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 239 285 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF 6R XXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 240 285 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9B XXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Line Item Control Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 241 285 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Facility Tax Amount To indicate the total monetary amount Usage notes Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Facility Tax Amount. Example AMT N8 0 Variants (all may be used) AMT Service Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount N8 Miscellaneous Taxes AMT-02 782 Facility Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 242 285 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Service Tax Amount To indicate the total monetary amount Usage notes Required when a service tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Service Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Service Tax Amount. Example AMT GT 000000000000000 Variants (all may be used) AMT Facility Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount GT Goods and Services Tax AMT-02 782 Service Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 243 285 NTE 4850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTE TPO XX Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 244 285 HCP 4920 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop HCP Line Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 14 00000000 00000000000000 X 0000000 XXX 00 0 XX HP XXXXXX DA 000000000000 T6 4 4 If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Quantity (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 Pricing HCP-02 782 Monetary Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 245 285 HCP02 is the allowed amount. HCP-03 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Rate Min 1 Max 9 Decimal number (R) Optional Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 246 285 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Product or Service ID Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type source of the descriptive number used in Product Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 247 285 Identifying number for a product or service HCP10 is the approved procedure code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 248 285 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 249 285 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop LIN Drug Identification To specify basic item identification data Usage notes Drugs and biologics reported in this segment are a further specification of service(s) described in the SV2 segment of this Service Line Loop ID-2400. Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. If not required by this implementation guide, do not send. Example LIN N4 XXXX Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) LIN02 through LIN31 provide for fifteen different product service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. N4 National Drug Code in 5-4-2 Format LIN-03 234 National Drug Code Min 1 Max 48 String (AN) Required Identifying number for a product or service 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 250 285 CTP 4940 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop CTP Drug Quantity To specify pricing information Example CTP 000 F2 Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes CTP04 must be greater than 0 and less than or equal to 9,999,999.999. CTP04 is limited to up to 3 decimal positions. CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 251 285 2410 Drug Identification Loop end REF 4950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop REF Prescription or Compound Drug Association Number To specify identifying information Usage notes In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REF VY X Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 252 285 2420A Operating Physician Name Loop Max 1 Optional Variants (all may be used) Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Operating Physician Name Loop NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. AND The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level). If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Example NM1 72 1 XX XXXXX X XXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 253 285 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 254 285 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Operating Physician Name Loop REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXXX 2U XXXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 255 285 2420A Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 256 285 2420B Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Other Operating Physician Name Loop NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved, AND The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level). If not required by this implementation guide, do not send.; Example NM1 ZZ 1 X X XXXX XXXXXX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating | /kaggle/input/edi-db-835-837/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_7 |
necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXXX 2U XXXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 255 285 2420A Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 256 285 2420B Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Other Operating Physician Name Loop NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved, AND The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level). If not required by this implementation guide, do not send.; Example NM1 ZZ 1 X X XXXX XXXXXX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 257 285 Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 258 285 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Other Operating Physician Name Loop REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXXXX 2U XXXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 259 285 2420B Other Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 260 285 2420C Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim. AND State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) AND The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Example NM1 82 1 XXXXX XXXXX XXXX X XX XX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 261 285 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 262 285 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 0B X 2U XXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 263 285 2420C Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 264 285 2420D Referring Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. AND The Referring Provider for this line is different than the Referring Provider reported in Loop ID 2310F (claim level). If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Example NM1 DN 1 XXX X XX XX XX XXXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 265 285 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 266 285 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 0B XX 2U XXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 267 285 2420D Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 268 285 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD XX 00000000000000 HP XX XX XX XX XX XXXXXX XX X 0000 00 Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Usage notes Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01). Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 269 285 If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. Usage notes Must be greater than zero. Must be less than or equal to 999,999.9. Must be 0 or 1 decimal position. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 270 285 C003-06 modifies the value in C003-02 and C003-08. Usage notes Must be an integer (no decimals). C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-04 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SVD04 is the revenue code. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 271 285 CAS 5450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS OA X 0000 00000000000 XXXXX 0000000 00 X 0 00 000000 XX 0 000 X 00 00000 XX 000000 00 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 272 285 CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 273 285 CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 274 285 Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 275 285 DTP 5500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP 573 D8 X Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage notes Must not be a future date. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 276 285 2430 Line Adjudication Information Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end 2000B Subscriber Hierarchical Level Loop end 2000A Billing Provider Hierarchical Level Loop end AMT 5505 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount SE 5550 Detail SE Max use 1 Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 277 285 Detail end Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 0 0001 SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 278 285 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 00 000000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 279 285 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 00000 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 280 285 EDI Samples Example 1a: Institutional Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231031 0142 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231031 014228 000000001 X 005010X223A3 ST 837 987654 005010X223A3 BHT 0019 00 0123 19960918 0932 CH NM1 41 2 JONES HOSPITAL 46 12345 PER IC JANE DOE TE 9005555555 NM1 40 2 MEDICARE 46 00120 HL 1 20 1 PRV BI PXC 203BA0200N NM1 85 2 JONES HOSPITAL XX 9876540809 N3 225 MAIN STREET BARKLEY BUILDING N4 CENTERVILLE PA 17111 REF EI 567891234 PER IC CONNIE TE 3055551234 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 DMG D8 19261111 M NM1 PR 2 MEDICARE B PI 00435 REF G2 330127 CLM 756048Q 89.93 14 A 1 A Y Y DTP 434 RD8 19960911 CL1 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 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 GE 1 000000001 IEA 1 000000001 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 281 285 Example 1b: Two Claims for the Same Provider ISA 00 00 ZZ SENDER ZZ RECEIVER 231031 0142 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231031 014255 000000001 X 005010X223A3 ST 837 987654 005010X223A3 BHT 0019 00 0123 20050630 0932 CH NM1 41 2 JONES HOSPITAL 46 12345 PER IC JANE DOE TE 1112223333 NM1 40 2 TRICARE 46 99999 HL 1 20 1 PRV BI PXC 282N00000X NM1 85 2 JONES HOSPITAL XX 1234567890 N3 225 MAIN 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 CENTERVILLE PA 17111 DMG D8 19681111 M NM1 PR 2 TRICARE PI 99999 CLM 756048Q 89.95 13 A 1 C Y Y DTP 434 RD8 20050315-20050315 CL1 1 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 SBR 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 TRICARE PI 99999 CLM 756049Q 50 13 A 1 C Y Y DTP 434 RD8 20050401-20050401 CL1 1 01 HI BK 30000 NM1 71 1 JONES JUDY J XX 9999999999 PRV AT PXC 363LP0200N LX 1 SV2 0300 HC 85087 50 UN 1 DTP 472 D8 20050401 SE 48 987654 GE 1 000000001 IEA 1 000000001 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 282 285 Example 1c: PPO Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231108 0220 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231108 022053 000000001 X 005010X223A3 ST 837 1002 005010X223A3 BHT 0019 00 1002 20050721 09460000 CH NM1 41 2 REGIONAL PPO NETWORK 46 123456789 PER IC SUBMITTER CONTACT INFO TE 8001231234 NM1 40 2 LOCAL INSURANCE COMPANY 46 54334452 HL 1 20 1 NM1 85 2 GOOD HEALTH HOSPITAL XX 1257234346 N3 592 NORTH ELM STREET N4 EDGEWOOD AZ 860015590 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 CLM 456DFH43 237.5 13 A 1 A Y Y DTP 434 RD8 20050706-20050706 DTP 435 DT 200507060800 CL1 1 2 01 AMT F3 237.5 REF 9A 09459034092 REF D9 04566877634343456 HI BK 38181 HI BF 38900 HI BH 11 D8 20050706 HCP 03 182.88 54.62 123456789 NM1 71 1 JOHNSON SIMON XX 5544332211 SBR S 19 T T PLUMBING COMPANY CI OI Y Y NM1 IL 1 JONES GEORGE MI 56454566 NM1 PR 2 OTHER COVERAGE COMPANY PI 534524 LX 1 SV2 0471 HC 92557 178 UN 1 DTP 472 D8 20050706 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 42 1002 GE 1 000000001 IEA 1 000000001 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 283 285 Example 1d: Out of Network Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231031 0143 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231031 014349 000000001 X 005010X223A3 ST 837 1024 005010X223A3 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 1122334455 N3 3423 SMALL STREET N4 COLUMBUS OH 432150000 REF EI 111002222 HL 2 1 22 0 SBR P 18 34561W CI NM1 IL 1 SMITH JAMES A MI 34902390F N3 934 NORTH STREET N4 COLUMBUS OH 432150000 DMG D8 19621015 M NM1 PR 2 CONSERVATIVE INSURANCE PI 0012 CLM W392-49141 14.84 13 A 1 A Y Y DTP 434 RD8 20050617-20050617 DTP 435 DT 200506170800 CL1 1 1 01 AMT F3 14.84 REF 9A 459804390823 REF D9 32423466233 HI BK 53081 HCP 00 0 333001234 T1 NM1 71 1 RIVERS DAWN XX 2244224455 LX 1 SV2 0301 HC 82270 14.84 UN 1 DTP 472 D8 20050617 SE 31 1024 GE 1 000000001 IEA 1 000000001 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 284 285 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 2a: Automobile Accident ISA 00 00 ZZ SENDER ZZ RECEIVER 231108 0222 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231108 022219 000000001 X 005010X223A3 ST 837 557766 005010X223A3 BHT 0019 00 0324 20051111 1800 CH NM1 41 2 HALL OF FAME MEMORIAL HOSPITAL 46 737373737 PER IC KATE CASEY TE 7152569877 NM1 40 2 HEISMAN INSURANCE COMPANY 46 999888777 HL 1 20 1 PRV BI PXC 203BA0200N NM1 85 2 HALL OF FAME MEMORIAL HOSPITAL XX 2365259638 N3 1 CANTON 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 CLM 67236695521 545 13 A 1 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 98765 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 472 D8 20051031 LX 4 SV2 0360 HC 99283 220 UN 1 DTP 472 D8 20051031 SE 36 557766 GE 1 000000001 IEA 1 000000001 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 285 285 | /kaggle/input/edi-db-835-837/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_8 |
1 837 Companion Guide Refers to the Implementation Guides based on the HIPAA Transaction ASC X12N. Standards for Electronic Data Interchange X12N 005010x222 Health Care Claim: Professional (837P) and ASC X12N 005010x223 Health Care Claim: Institutional (837I) October 2016 2 Overview The Companion Guide provides Centene trading partners with guidelines for submitting the ASC X12N 005010x222 Health Care Claim: Professional (837P) and ASC X12N 005010x223 Health Care Claim: Institutional (837I). The Centene Companion Guide documents any assumptions, conventions, or data issues that may be specific to Centene business processes when implementing the HIPAA ASC X12N 5010A Technical Reports Type 3 (TR3). As such, this Companion Guide is unique to Centene and its affiliates. This document does NOT replace the HIPAA ASC X12N 5010A Technical Reports Type 3 (TR3) for electronic transactions, nor does it attempt to amend any of the rules therein or impose any mandates on any trading partners of Centene. This document provides information on Centene- specific code handling and situation handling that is within the parameters of the HIPAA administrative Simplification rules. Readers of this Companion Guide should be acquainted with the HIPAA Technical Reports Type 3, their structure and content. Information contained within the HIPAA TR3s has not been repeated here although the TR3s have been referenced when necessary. The HIPAA ASC X12N 5010A Technical Reports Type 3 (TR3) can be purchased at http: store.x12.org. The Companion Guide provides supplemental information to the Trading Partner Agreement (TPA) that exists between Centene and its trading partners. Refer to the TPA for guidelines pertaining to Centene legal conditions surrounding the implementations of EDI transactions and code sets. Refer to the Companion Guide for information on Centene business rules or technical requirements regarding the implementation of HIPAA compliant EDI transactions and code sets. Nothing contained in this guide is intended to amend, revoke, contradict, or otherwise alter the terms and conditions of the Trading Partner Agreement. If there is an inconsistency with the terms of this guide and the terms of the Trading Partner Agreement, the terms of the Trading Partner Agreement shall govern. Express permission to use X12 copyrighted materials within this document has been granted. Rules of Exchange The Rules of Exchange section details the responsibilities of trading partners in submitting or receiving electronic transactions with Centene. Transmission Confirmation Transmission confirmation may be received through one of two possible transactions: the ASC X12C 005010X231 Implementation Acknowledgment For Health Care Insurance (TA1, 999). A TA1 Acknowledgement is used at the ISA level of the transmission envelope structure, to confirm a positive transmission or indicate an error at the ISA level of the transmission. The 999 Acknowledgement may be used to verify a successful transmission or to indicate various types of errors. 3 Transmission Confirmation cont. Confirmations of transmissions, in the form of TA1 or 999 transactions, should be received within 24 hours of batch submissions, and usually sooner. Senders of transmissions should check for confirmations within this time frame. Batch Matching Senders of batch transmissions should note that transactions are unbundled during processing, and rebundled so that the original bundle is not replicated. Trace numbers or patient account numbers should be used for batch matching or batch balancing. TA1 Interchange Acknowledgement The TA1 Interchange Acknowledgement provides senders a positive or negative confirmation of the transmission of the ISA IEA Interchange Control. 999 Functional Acknowledgement The 999 Functional Acknowledgement reports on all Implementation Guide edits from the Functional Group and transaction Sets. 277CA Health Care Claim Acknowledgement The X12N005010X214 Health Care Claim Acknowledgment (277CA) provides a more detailed explanation of the transaction set. Centene also provides the Pre-Adjudication rejection reason of the claim within the STC12 segment of the 2220D loop. NOTE: The STC03 Action Code will only be a U if the claim failed on HIPAA validation errors, NOT Pre-Adjudication errors. Duplicate Batch Check To ensure that duplicate transmissions have not been sent, Centene checks five values within the ISA for redundancy: ISA06, ISA08, ISA09, ISA10, ISA13 Collectively, these numbers should be unique for each transmission. A duplicate ISA IEA receives a TA1 response of 025 (Duplicate Interchange Control Number). Duplicate Batch Check cont. To ensure that Transaction Sets (ST SE) have not been duplicated within a transmission, Centene checks the ST02 value (Transaction Set Control Number), which should be a unique ST02 within the Functional Group transmitted. Note: ISA08 GS03 could also be the Single Payer ID 4 New Trading Partners New trading partners should access https: www.centene.com edifecs, register for access, and perform the steps in the Centene trading partner program. The EDI Support Desk (EDIBA Centene.com) will contact you with additional steps necessary upon completing your registration. Claims Processing Acknowledgements Senders receive four types of acknowledgement transactions: the TA1 transaction to acknowledge the Interchange Control Envelope (ISA IEA) of a transaction, the 999 transaction to acknowledge the Functional Group (GS GE) and Transaction Set (ST SE), the 277CA transaction to acknowledge health care claims, and the Centene Audit Report. At the claim level of a transaction, the only acknowledgement of receipt is the return of the Claim Audit Report and or a 277CA. Coordination of Benefits (COB) Processing To ensure the proper processing of claims requiring coordination of benefits, Centene recommends that providers validate the patient s Membership Number and supplementary or primary carrier information for every claim. Code Sets Only standard codes, valid at the time of the date(s) of service, should be used. Corrections and Reversals The 837 defines what values submitters must use to signal payers that the Inbound 837 contains a reversal or correction to a claim that has previously been submitted for processing. For both Professional and Institutional 837 claims, 2300 CLM05-3 (Claim Frequency Code) must contain a value for the National UB Data Element Specification Type List Type of Bill Position 3. Data Format Content Centene accepts all compliant data elements on the 837 Professional Claim. The following points outline consistent data format and content issues that should be followed for submission. Dates The following statements apply to any dates within an 837 transaction: All dates should be formatted according to Year 2000 compliance, CCYYMMDD, except for ISA segments where the date format is YYMMDD. The only values acceptable for CC (century) within birthdates are 18, 19, or 20. Dates that include hours should use the following format: CCYYMMDDHHMM. Use Military format, or numbers from 0 to 23, to indicate hours. For example, an admission date of 201006262115 defines the date and time of June 26, 2010 at 9:1 5 PM. No spaces or character delimiters should be used in presenting dates or times. 5 Dates that are logically invalid (e.g. 20011301) are rejected. Dates must be valid within the context of the transaction. For example, a patient s birth date cannot be after the patient s service date. Decimals All percentages should be presented in decimal format. For example, a 12.5 value should be presented as.125. Dollar amounts should be presented with decimals to indicate portions of a dollar; however, no more than two positions should follow the decimal point. Dollar amounts containing more than two positions after the decimal point are rejected. Monetary and Unit Amount Values Centene accepts all compliant data elements on the 837 Professional Claim; however, monetary or unit amount values that are in negative numbers are rejected. Delimiters Delimiters are characters used to separate data elements within a data string. Delimiters suggested for use by Centene are specified in the Interchange Header segment (the ISA level) of a transmission; these include the tilde ( ) for segment separation, the asterisk ( ) for element separation, and the colon (:) for component separation. Phone Numbers Phone numbers should be presented as contiguous number strings, without dashes or parenthesis markers. For example, the phone number (336) 555-1212 should be presented as 3365551212. Area codes should always be included. Centene requires the phone number to be AAABBBCCCC where AAA is the Area code, BBB is the telephone number prefix, and CCCC is the telephone number. Additional Items Centene will not accept more than 97 service lines per UB-04 claim. Centene will not accept more than 50 service lines per CMS 1500 claim. Centene will only accept single digit diagnosis pointers in the SV107 of the 837P. The Value Added Network Trace Number (2300-REF02) is limited to 30 characters. 6 Identification Codes and Numbers General Identifiers Federal Tax Identifiers Any Federal Tax Identifier (Employer ID or Social Security Number) used in a transmission should omit dashes or hyphens. Centene sends and receives only numeric values for all tax identifiers. Sender Identifier The Sender Identifier is presented at the Interchange Control (ISA06) of a transmission. Centene expects to see the sender s Federal Tax Identifier (ISA05, qualifier 30) for this value. In special circumstances, Centene will accept a Mutually Defined (ZZ) value. Senders wishing to submit a ZZ value must confirm this identifier with Centene EDI. Payer Identifier Single Payer IDs are used for all Health Plans. Please verify directly with the Health Plan and or Clearinghouse the Payer ID that should be used or contact the EDI Support Desk at 800 225 2573 X6075525 or EDIBA centene.com. Plan Receiver ID Payer ID All ISA08 GS03 837P 837I NMN109 when NM101 PR Medical 68069 68069 Behavioral Health CBH 68068 68068 Centurion 42140 42140 Provider Identifiers National Provider Identifiers (NPI) HIPAA regulation mandates that providers use their NPI for electronic claims submission. The NPI is used at the record level of HIPAA transactions; for 837 claims, it is placed in the 2010AA loop. See the 837 Professional Data Element table for specific instructions about where to place the NPI within 7 the 837 Professional file. The table also clarifies what other elements must be submitted when the NPI is used. Billing provider The Billing Provider Primary Identifier should be the group organization ID of the billing entity, filed only at 2010AA. This will be a Type 2 (Group) NPI unless the Billing provider is a sole proprietor and processes all claims and remittances with a Type 1 (Individual) NPI. Rendering Provider When providers perform services for a subscriber patient, the service will need to be reported in the Rendering Provider Loop (2310B or 2420A) You should only use 2420A when it is different than Loop 2310B NM1 82. Referring Provider Centene has no specific requirements for Referring Provider information. Atypical Provider Atypical providers are not always assigned an NPI number, however, if an Atypical provider has been assigned an NPI, then they need to follow the same requirements as a medical provider. An Atypical provider which provides non-medical services is not required to have an NPI number (i.e. carpenters, transportation, etc). Existing Atypical providers need only send the Provider Tax ID in the REF segment of the billing provider loop. NOTE: If an NPI is billed in any part of the claim, it will not follow the Atypical Provider Logic. Subscriber Identifiers Submitters must use the entire identification code as it appears on the subscriber s card in the 2010BA element. Claim Identifiers Centene issues a claim identification number upon receipt of any submitted claim. The ASC X12 Technical Reports (Type 3) may refer to this number as the Internal Control Number (ICN), Document Control Number (DCN), or the Claim Control Number (CCN). It is provided to senders in the Claim Audit Report and in the CLP segment of an 835 transaction. Centene returns the submitter s Patient Account Number (2300, CLM01) on the Claims Audit Report and the 835 Claim Payment Advice (CLP01). 8 Connectivity Media for Batch Transactions Secure File Transfer Centene encourages trading partners to consider a secure File Transfer Protocol (FTP) transmission option. Centene offers two options for connectivity via FTP. Method A the trading partner will push transactions to the Centene FTP server and Centene will push outbound transactions to the Centene FTP server. Method B The Trading partner will push transactions to the Centene FTP server and Centene will push outbound transactions to the trading partner s FTP server. Encryption Centene offers the following methods of encryption SSH SFTP, FTPS (Auth TLS), FTP w PGP, HTTPS (Note this method only applies with connecting to Centene s Secure FTP. Centene does not support retrieve files automatically via HTTPS from an external source at this time.) If PGP or SSH keys are used they will shared with the trading partner. These are not required for those connecting via SFTP or HTTPS. Direct Submission Centene also offers posting an 837 batch file directly on the Provider Portal website for processing. Edits and Reports Incoming claims are reviewed first for HIPAA compliance and then for Centene business rules requirements. The business rules that define these requirements are identified in the 837 Professional Data Element Table below, and are also available as a comprehensive list in the 837 Professional Claims Centene Business Edits Table. HIPAA TR3 implementation guide errors may be returned on either the TA1 or 999 while Centene business edit errors are returned on the Centene Claims Audit Report. Reporting The following table indicates which transaction or report to review for problem data found within the 837 Professional Claim Transaction. Transaction Structure Level Type of Error or Problem Transaction or Report Returned ISA IEA Interchange Control TA1 GS GE Functional Group ST SE Segment Detail Segments HIPAA Implementation Guide violations 999 Centene Claims Audit Report (a proprietary confirmation and error report) Detail Segments Centene Business Edits (see audit report rejection reason codes and explanation.) Centene Claims Audit Report (a proprietary confirmation and error report) Detail Segments HIPAA Implementation Guide violations and Centene Business Edits. 277CA 9 277CA Audit Report Rejection Codes Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB Provider 08 Invalid Mbr Provider 09 Mbr not valid at DOS 10 Invalid Mbr DOB; Mbr not valid at DOS 12 Provider not valid at DOS 13 Invalid Mbr DOB; Prv not valid at DOS 14 Invalid Mbr; Prv not valid at DOS 15 Mbr not valid at DOS; Invalid Prv 16 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv 17 Invalid Diag Code 18 Invalid Mbr DOB; Invalid Diag 19 Invalid Mbr; Invalid Diag 21 Mbr not valid at DOS; Prv not valid at DOS 22 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS 23 Invalid Prv; Invalid Diagnosis Code 24 Invalid Mbr DOB; Invalid Prv; Invalid Diag Code 25 Invalid Mbr; Invalid Prv; Invalid Diag Code 26 Mbr not valid at DOS; Invalid Diag Code 27 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Diag Code 10 Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB Provider 29 Provider not valid at DOS; Invalid Diag Code 30 Invalid Mbr DOB; Prv not valid at DOS; Invalid Diag 31 Invalid Mbr; Prv not valid at DOS; Invalid Diag 32 Mbr not valid at DOS; Prv not valid; Invalid Diag 33 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv; Invalid Diag 34 Invalid Proc 35 Invalid Mbr DOB; Invalid Proc 36 Invalid Mbr; Invalid Proc 37 Invalid Future Service Date 38 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 39 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 40 Invalid Prv; Invalid Proc 41 Invalid Mbr DOB, Invalid Prv; Invalid Proc 42 Invalid Mbr; Invalid Prv; Invalid Proc 43 Mbr not valid at DOS; Invalid Proc 44 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Proc 46 Prv not valid at DOS; Invalid Proc 48 Invalid Mbr; Prv not valid at DOS; Invalid Proc 49 Mbr not valid at DOS; Invalid Prv; Invalid Proc 51 Invalid Diag; Invalid Proc 11 Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB Provider 52 Invalid Mbr DOB; Invalid Diag; Invalid Proc 53 Invalid Mbr; Invalid Diag; Invalid Proc 55 Mbr not valid at DOS; Prv not valid at DOS; Invalid Proc 57 Invalid Prv; Invalid Diag; Invalid Proc 58 Invalid Mbr DOB; Invalid Prv; Invalid Diag; Invalid Proc 59 Invalid Mbr; Invalid Prv; Invalid Diag; Invalid Proc 60 Mbr not valid at DOS;Invalid Diag;Invalid Proc 61 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Diag; Invalid Proc 63 Prv not valid at DOS; Invalid Diag; Invalid Proc 64 Invalid Mbr DOB; Prv not valid at DOS; Invalid Diag; Invalid Proc 65 Invalid Mbr; Prv not valid at DOS; Invalid Diag; Invalid Proc 66 Mbr not valid at DOS; Invalid Prv; Invalid Diag; Invalid Proc 67 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv; Invalid Diag; Invalid Proc 72 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag; Invalid Proc 73 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag; Invalid Proc 74 Services performed prior to Contract Effective Date 75 Invalid units of service 76 Original Claim Number Required 77 Invalid Claim Type 78 Diagnosis Pointer- Not in sequence or incorrect length 12 Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB Provider 81 Invalid units of service, Invalid Prv 83 Invalid units of service, Invalid Prv, Invalid Mbr 89 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 91 Invalid Missing Taxonomy or NPI Invalid Prov 92 Invalid Referring Ordering NPI 93 Mbr not valid at DOS; Invalid Proc 96 GA OPR NPI Registration-State A2 Diagnosis Pointer Invalid A3 Service Lines- Greater than 97 Service lines submitted- Invalid B1 Rendering and Billing NPI are not tied on State File- IN rejection B2 Not enrolled with MHS IN and or State with rendering NPI TIN on DOS. Enroll with MHS and Resubmit claim B5 Invalid CLIA C7 NPI Registration- State GA OPR C9 Invalid Missing Attending NPI HP H1 H2 ICD9 after end date ICD10 sent before Eff Date Mixed ICD versions | /kaggle/input/edi-db-835-837/508_Centene_5010_837_Companion_Guide.pdf | 65e053b3ae1844937cfa041f22d74ce3 | 65e053b3ae1844937cfa041f22d74ce3_0 |
837 Institutional Companion Guide Version 38.0 July 2016. 1 Centers for Medicare Medicaid Services (CMS) Logo. _________________________________________________________________ Medicare Encounter Data System Standard Companion Guide Transaction Information Instructions related to the 837 Health Care Claim: Institutional Transaction based on ASC X12 Technical Report Type 3 (TR3), Version 005010X223A2 Companion Guide Version Number: 38.0 Created: July 2016 837 Institutional Companion Guide Version 38.0 July 2016. 2 Table of Contents Table of Contents..........................................................................................................................................................2 Preface................................................................................................................................................................................6 1.0 Introduction.......................................................................................................................................................7 1.1 Scope.................................................................................................................................................................7 1.2 Overview.........................................................................................................................................................7 1.3 Major Updates..............................................................................................................................................7 1.3.1 EDFES Notifications.....................................................................................................................................7 1.3.2 EDIPPS Edits and EDIPPS Edits Enhancements Implementation Updates................................7 1.3.3 EDIPPS Edits Prevention and Resolution Strategies Scenarios Updates..................................8 1.4 References......................................................................................................................................................8 2.0 Contact Information.......................................................................................................................................9 2.1 The Customer Service and Support Center (CSSC)....................................................................9 2.2 Applicable Websites Email Resources............................................................................................9 3.0 File Submission................................................................................................................................................9 3.1 File Size Limitations..................................................................................................................................9 3.2 File Structure NDM Connect Direct and Gentran TIBCO Submitters Only............ 10 4.0 Control Segments Envelopes................................................................................................................. 10 4.1 ISA IEA......................................................................................................................................................... 10 4.2 GS GE............................................................................................................................................................ 12 4.3 ST SE............................................................................................................................................................. 13 5.0 Transaction Specific Information......................................................................................................... 13 5.1 837 Institutional: Data Element Table......................................................................................... 13 6.0 Acknowledgements and or Reports................................................................................................... 18 6.1 TA1 Interchange Acknowledgement.......................................................................................... 18 6.2 999 Functional Group Acknowledgement............................................................................... 19 6.3 277CA Claim Acknowledgement.................................................................................................. 19 6.4 MAO-001 Encounter Data Duplicates Report........................................................................ 20 6.5 MAO-002 Encounter Data Processing Status Report.......................................................... 20 6.6 Reports File Naming Conventions................................................................................................... 21 6.6.1 Testing Reports File Naming Convention.................................................................................. 21 837 Institutional Companion Guide Version 38.0 July 2016. 3 6.6.2 Production Reports File Naming Convention........................................................................... 22 6.7 EDFES Notifications................................................................................................................................ 23 7.0 Front-End Edits............................................................................................................................................. 25 7.1 Deactivated Front-End Edits.............................................................................................................. 25 7.2 Temporarily Deactivated Front-End Edits.................................................................................. 28 7.3 New EDFES Edits..................................................................................................................................... 28 8.0 Duplicate Logic.............................................................................................................................................. 28 8.1 Header Level.............................................................................................................................................. 29 8.2 Detail Level................................................................................................................................................. 29 9.0 837 Institutional Business Cases.......................................................................................................... 29 9.1 Standard Institutional Encounter.................................................................................................... 31 9.2 Capitated Institutional Encounter................................................................................................... 33 9.3 Chart Review Institutional Encounter No Linked ICN....................................................... 35 9.4 Chart Review Institutional Encounter Linked ICN (Add Diagnoses).......................... 37 9.5 Chart Review Institutional Encounter Linked ICN (Delete Diagnoses)..................... 39 9.6 Complete Replacement Institutional Encounter...................................................................... 41 9.7 Complete Deletion Institutional Encounter................................................................................ 43 9.8 Atypical Provider Institutional Encounter.................................................................................. 45 9.9 Paper Generated Institutional Encounter.................................................................................... 47 9.10 True Coordination of Benefits Institutional Encounter........................................................ 49 9.11 Bundled Institutional Encounter..................................................................................................... 51 9.12 Skilled Nursing Facility Encounter.................................................................................................. 53 10.0 Encounter Data Institutional Processing and Pricing System Edits.................................... 55 10.1 EDIPPS Edits Enhancements Implementation Dates............................................................. 59 10.2 EDIPPS Edits Prevention and Resolution Strategies.............................................................. 59 10.2.1 EDIPPS Edits Prevention and Resolution Strategies Phase I: Frequently Generated EDIPPS Edits.......................................................................................................................................................... 59 10.2.2 EDIPPS Edits Prevention and Resolution Strategies Phase II: Common EDPS Edits 61 10.2.3 EDIPPS Edit Prevention and Resolution Strategies Phase III: General EDIPPS Edits 65 11.0 Submission of Default Data in a Limited Set of Circumstances.............................................. 85 837 Institutional Companion Guide Version 38.0 July 2016. 4 11.1 Default Data Reason Codes (DDRC)................................................................................................ 85 12.0 Tier II Testing................................................................................................................................................. 86 13.0 EDS Acronyms................................................................................................................................................ 87 837 Institutional Companion Guide Version 38.0 July 2016. 5 List of Tables TABLE 1 ISA IEA INTERCHANGE ELEMENTS......................................................................................... 11 TABLE 2 GS GE FUNCTIONAL GROUP ELEMENTS............................................................................... 12 TABLE 3 ST SE TRANSACTION SET HEADER AND TRAILER ELEMENTS................................. 13 TABLE 4 837 INSTITUTIONAL HEALTH CARE CLAIM......................................................................... 14 TABLE 5 TESTING EDFES REPORTS FILE NAMING CONVENTIONS............................................. 22 TABLE 6 TESTING EDPS REPORTS FILE NAMING CONVENTIONS............................................... 22 TABLE 7 FILE NAME COMPONENT DESCRIPTION................................................................................ 22 TABLE 8 PRODUCTION EDFES REPORTS FILE NAMING CONVENTIONS.................................. 23 TABLE 9 PRODUCTION EDPS REPORTS FILE NAMING CONVENTIONS..................................... 23 TABLE 10 EDFES NOTIFICATIONS................................................................................................................ 24 TABLE 11 837 INSTITUTIONAL DEACTIVATED EDFES EDITS....................................................... 26 TABLE 12 837 INSTITUTIONAL TEMPORARILY DEACTIVATED edfes EDITS........................ 28 TABLE 13 837 NEW INSTITUTIONAL EDFES EDITS............................................................................ 28 TABLE 14 ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS........................................................................................................................................................... 56 TABLE 15 EDIPPS EDITS ENHANCEMENTS IMPLEMENTATION DATES................................... 59 TABLE 16 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE I.......... 59 TABLE 17 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE II........ 61 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III....... 65 TABLE 19 DEFAULT DATA................................................................................................................................ 85 TABLE 20 EDS ACRONYMS................................................................................................................................ 87 TABLE 21 - REVISION HISTORY......................................................................................................................... 90 837 Institutional Companion Guide Version 38.0 July 2016. 6 Preface The Encounter Data System (EDS) Companion Guide contains information to assist Medicare Advantage Organizations (MAOs) and other entities in the submission of encounter data. The EDS Companion Guide is continually under development and the information in this version reflects current decisions and will be modified on a regular basis. All of the EDS Companion Guides are identified with a version number, located in the version control log on the last page of the document. Users should verify that they are using the most current version. Questions regarding the content of the EDS Companion Guide should be directed to encounterdata cms.hhs.gov. 837 Institutional Companion Guide Version 38.0 July 2016. 7 1.0 Introduction 1.1 Scope The Centers for Medicare and Medicaid Services (CMS) EDS 837-I Companion Guide addresses how MAOs and other entities conduct Institutional claims under Health Information Portability and Accountability Act (HIPAA) standard electronic transactions with CMS. The CMS EDS supports transactions adopted under HIPAA, as well as additional supporting transactions described in this guide. The CMS EDS 837-I Companion Guide must be used in conjunction with the associated 837-I Technical Report Type 3 (TR3) and the CMS 5010 Edits Spreadsheets. The instructions in the 837-I CMS EDS Companion Guide are not intended for use as a stand-alone requirements document. 1.2 Overview The CMS EDS 837-I Companion Guide includes information required to initiate and maintain communication exchange with CMS. The information is organized in the sections listed below: Contact Information: Includes telephone numbers and email addresses for EDS contacts. Control Segments Envelopes: Contains information required to create the ISA IEA, GS GE, and ST SE control segments in order for transactions to be supported by the EDS. Acknowledgements and Reports: Contains information for all transaction acknowledgements and reports sent by the EDS. Transaction Specific Information: Describes the details of the HIPAA X12 TR3 using a tabular format. The tables contain a row for each segment with CMS and TR3 specific information. That information may contain: o o o o o Limits on the repeat of loops or segments Limits on the length of a simple data element Specifics on a sub-set of the Implementation Guide s (IG) s internal code listings Clarification of the use of loops, segments, and composite or simple data elements Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with CMS. In addition to the row for each segment, one (1) or more additional rows are used to describe the EDS usage for composite or simple data elements and for any other information. 1.3 Major Updates 1.3.1 EDFES Notifications MAOs and other entities may reference Section 6.7, Table 10 for new EDFES notifications. 1.3.2 EDIPPS Edits and EDIPPS Edits Enhancements Implementation Updates MAOs and other entities may reference Section 10.0, Table 14 and Section 10.1, Table 15 for new edits in the EDIPPS. 837 Institutional Companion Guide Version 38.0 July 2016. 8 1.3.3 EDIPPS Edits Prevention and Resolution Strategies Scenarios Updates MAOs may reference Section 10.2.3, Table 18 for new and updated Prevention and Resolution Strategies and scenarios for EDIPPS edits. MAOs and other entities must use the ASC X12N TR3 adopted under the HIPAA Administrative Simplification Electronic Transaction rule, along with CMS EDS Companion Guides, for development of the EDS transactions. These documents are accessible on the CSSC Operations website at http: www.csscoperations.com. Additionally, CMS publishes the EDS submitter guidelines and application, testing documents, and 837 EDS Companion Guides on the CSSC Operations website. 1.4 References MAOs and other entities must use the most current national standard code lists applicable to the 5010 transaction. The code lists is accessible at the Washington Publishing Company (WPC) website at: http: www.wpc-edi.com. The applicable code lists are as follows: Claim Adjustment Reason Code (CARC) Claim Status Category Codes (CSCC) Claim Status Codes (CSC) CMS provides X12 5010 file format technical edit spreadsheets (CMS 5010 Edits Spreadsheets) for the 837-I, 837-P, and 837-DME modules. The edits included in the spreadsheets are provided to clarify the WPC instructions or add Medicare specific requirements. In order to determine the implementation date of the edits contained in the spreadsheet, MAOs and other entities should initially refer to the spreadsheet version identifier. The version identifier is comprised of ten (10) characters, as follows: Positions 1-2 indicate the line of business: o o o EA Part A (837-I) EB Part B (837-P) CE DME Part B Drugs Positions 3-6 indicate the year (e.g., 2015) Position 7 indicates the release quarter month o o o o 1 January release 2 April release 3 July release 4 October release Positions 8-10 indicate the spreadsheet version iteration number (e.g., V01-first iteration, V02- second iteration) The effective date of the spreadsheet is the first calendar day of the release quarter month. The implementation date is the first business Monday of the release quarter month. Federal holidays that potentially occur on the first business Monday are considered when determining the implementation date. 837 Institutional Companion Guide Version 38.0 July 2016. 9 2.0 Contact Information 2.1 The Customer Service and Support Center (CSSC) The Customer Service and Support Center (CSSC) personnel are available for questions from 8:00 AM 7:00PM ET, Monday-Friday, with the exception of federal holidays. MAOs and other entities are able to contact the CSSC by phone at 1-877-534-CSSC (2772) or by email at csscoperations palmettogba.com. 2.2 Applicable Websites Email Resources The following websites provide information to assist in the EDS submission: EDS WEBSITE RESOURCES RESOURCE WEB ADDRESS EDS Inbox encounterdata cms.hhs.gov EDS Participant Guide http: www.csscoperations.com EDS User Group and Webinar Materials http: www.csscoperations.com ANSI ASC X12 TR3 http: www.wpc-edi.com Washington Publishing Company Health Care Code Sets http: www.wpc-edi.com CMS 5010 Edits Spreadsheets https: www.cms.gov Regulations-and-Guidance Guidance Transmittals 3.0 File Submission 3.1 File Size Limitations Due to system limitations, ISA IEA transaction sets should not exceed 5,000 encounters. Also, it is highly recommended that MAOs and other entities submit larger numbers of encounters within each ST SE transaction set, not to exceed 5,000 encounters. In an effort to support and provide the most efficient processing system, and to allow for maximum performance, CMS recommends that FTP submitters scripts upload no more than one (1) file per five (5) minute intervals. Zipped files should contain one (1) file per transmission. NDM and Gentran TIBCO users may submit a maximum of 255 files per day. These submission practices will assist with prevention of delays in the generation and distribution of EDFES Acknowledgement reports. Note: Due to system processing overhead associated with smaller numbers of encounters within the ST SE, it is highly recommended that MAOs and other entities submit larger numbers of encounters within the ST SE, not to exceed 5,000 encounters. In an effort to support and provide the most efficient processing system, and to allow for maximum performance, CMS recommends that FTP submitters scripts upload no more than one (1) file per five (5) minute intervals. Zipped files should contain one (1) file per transmission. MAOs and other entities 837 Institutional Companion Guide Version 38.0 July 2016. 10 should refrain from submitting multiple files within the same transmission. NDM and Gentran TIBCO users may submit a maximum of 255 files per day. 3.2 File Structure NDM Connect Direct and Gentran TIBCO Submitters Only NDM Connect Direct and Gentran TIBCO submitters must format all submitted files in an 80-byte fixed block format. This means MAOs and other entities must upload every line (record) in a file with a length of 80 bytes characters. Submitters should create files with segments stacked, using only 80 characters per line. At position 81 of each segment, MAOs and other entities must create a new line. On the new line starting in position 1, continue for 80 characters, and repeat creating a new line in position 81 until the file is complete. If the last line in the file does not fill to 80 characters, the submitter should space the line out to position 80 and then save the file. Note: If MAOs and other entities are using a text editor to create the file, pressing the Enter key will create a new line. If MAOs and other entities are using an automated system to create the file, create a new line by using a CRLF (Carriage Return Line Feed) or a LF (Line Feed). For example, the ISA record is 106 characters long: The first line of the file will contain the first 80 characters of the ISA segment; the last 26 characters of the ISA segment continue on the second line. The next segment will start in the 27th position and continue until column 80. ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: Note to NDM Connect:Direct Users: If a submitter has not established a sufficient number of Generated Data Groups (GDGs) to accommodate the number of files returned from the EDFES, not all of the EDFES Acknowledgement reports will be stored in the submitter s system. To prevent this situation, NDM Connect:Direct submitters should establish a limit of 255 GDGs in their internal processing systems. 4.0 Control Segments Envelopes 4.1 ISA IEA The term interchange denotes the transmitted ISA IEA envelope. Interchange control is achieved through several control components, as defined in Table 1. The interchange control number is contained in data element ISA13 of the ISA segment. The identical control number must also occur in data element IEA02 of the IEA segment. MAOs and other entities must populate all elements in the ISA IEA interchange. There are several elements within the ISA IEA interchange that must be populated specifically for encounter data purposes. Table 1 below provides EDS Interchange Control (ISA IEA) specific elements. Note: Table 1 presents only those elements that provide specific details relevant to encounter data. When developing the encounter data system, users should base their logic on the highest level of specificity. First, consult the WPC TR3. Second, consult the CMS 5010 Edits Spreadsheets. Third, 837 Institutional Companion Guide Version 38.0 July 2016. 11 consult the CMS EDS 837-I Companion Guide. If there are options expressed in the WPC TR3 or the CMS 5010 Edits Spreadsheets that are broader than the options identified in the CMS EDS 837-I Companion Guide, MAOs and other entities must use the rules identified in the Companion Guide. LEGEND TO TABLE 1 Legend SHADED rows represent segments in the X12N TR3 NON-SHADED rows represent data elements in the X12N TR3 TABLE 1 ISA IEA INTERCHANGE ELEMENTS LOOP ID REFERENCE NAME CODES NOTES COMMENTS ISA N A Interchange Control Header N A N A ISA ISA01 Authorization Information Qualifier 00 No authorization information present LOOP ID REFERENCE NAME CODES NOTES COMMENTS ISA ISA02 Authorization Information N A Use 10 blank spaces ISA ISA03 Security Information Qualifier 00 No security information present ISA ISA04 Security Information N A Use 10 blank spaces ISA ISA05 Interchange ID Qualifier ZZ CMS expects to see a value of ZZ to designate that the code is mutually defined ISA ISA06 Interchange Sender ID N A EN followed by Contract ID Number ISA ISA08 Interchange Receiver ID 80881 N A ISA ISA11 Repetition Separator N A ISA ISA13 Interchange Control Number N A Must be fixed length with nine (9) characters and match IEA02 Used to identify file level duplicate collectively with GS06, ST02, and BHT03 ISA ISA14 Acknowledgement Requested 1 A TA1 will be sent if the file is syntactically incorrect, otherwise only a 999 will be sent ISA ISA15 Usage Indicator T P Test Production IEA N A Interchange Control Trailer N A N A IEA IEA02 Interchange Control Number N A Must match the value in ISA13 837 Institutional Companion Guide Version 38.0 July 2016. 12 4.2 GS GE The functional group is outlined by the functional group header (GS segment) and the functional group trailer (GE segment). The functional group header starts and identifies one or more related transaction sets and provides a control number and application identification information. The functional group trailer defines the end of the functional group of related transaction sets and provides a count of contained transaction sets. MAOs and other entities must populate all elements in the GS GE functional group. There are several elements within the GS GE that must be populated specifically for encounter data collection. Table 2 provides EDS functional group (GS GE) specific elements. Note: Table 2 presents only those elements that require explanation. TABLE 2 GS GE FUNCTIONAL GROUP ELEMENTS LOOP ID REFERENCE NAME CODES NOTES COMMENTS GS N A Functional Group Header N A N A GS GS02 Application Sender s Code N A EN followed by Contract ID Number This value must match the value in the ISA06 GS GS03 Application Receiver s Code 80881 This value must match the value in ISA08 GS GS06 Group Control Number N A This value must match the value in GE02 Used to identify file level duplicates collectively with ISA13, ST02, and BHT03 GS GS08 Version Release Industry Identifier Code 005010X223A2 N A GE N A Functional Group Trailer N A N A GE GE02 Group Control Number N A This value must match the value in GS06 837 Institutional Companion Guide Version 38.0 July 2016. 13 4.3 ST SE The transaction set (ST SE) contains required, situational loops, unused loops, segments, and data elements. The transaction set is outlined by the transaction set header (ST segment) and the transaction set trailer (SE segment). The transaction set header identifies the start and identifies the transaction set. The transaction set trailer identifies the end of the transaction set and provides a count of the data segments, which includes the ST and SE segments. Several elements must be populated specifically for encounter data purposes. Table 3 provides EDS transaction set (ST SE) specific elements. Note: Table 3 presents only those elements that require explanation. TABLE 3 ST SE TRANSACTION SET HEADER AND TRAILER ELEMENTS LOOP ID REFERENCE NAME CODES NOTES COMMENTS ST N A Transaction Set Header N A N A ST ST01 Transaction Set Identifier Code 837 N A ST ST02 Transaction Set Control Number N A This value must match the value in SE02 Used to identify file level duplicates collectively with ISA13, GS06, and BHT03 ST ST03 Implementation Convention Reference 005010X223A2 N A SE N A Transaction Set Trailer N A N A SE SE01 Number of Included Segments N A Must contain the actual number of segments within the ST SE SE SE02 Transaction Set Control Number N A This value must be match the value in ST02 5.0 Transaction Specific Information 5.1 837 Institutional: Data Element Table Within the ST SE transaction set, there are multiple loops, segments, and data elements that provide billing provider, subscriber, and patient level information. MAOs and other entities should reference www.wpc-edi.com to obtain the most current TR3. MAOs and other entities must submit EDS transactions using the most current transaction version. The 837 Institutional Data Element table identifies only those elements within the X12N TR3 that require comment within the context of the EDS submission. Table 4 identifies the 837 Institutional TR3 by loop name, segment name, segment identifier, data element name, and data element identifier for cross reference. Not all data elements listed in the table below are required, but if they are used, the table reflects the values CMS expects to see. 837 Institutional Companion Guide Version 38.0 July 2016. 14 TABLE 4 837 INSTITUTIONAL HEALTH CARE CLAIM LOOP ID REFERENCE NAME CODES NOTES COMMENTS N A BHT Beginning of Hierarchical Transaction N A N A N A BHT03 Originator Application Transaction Identifier N A Must be a unique identifier across all files Used to identify file level duplicates collectively with ISA13, GS06, and ST02. N A BHT06 Claim Identifier CH Chargeable 1000A NM1 Submitter Name N A N A 1000A NM102 Entity Type Qualifier 2 Non-Person Entity 1000A NM109 Submitter Identifier N A EN followed by Contract ID Number 1000A PER Submitter EDI Contact Info N A N A 1000A PER03 Communication Number Qualifier TE It is recommended that MAOs and other entities populate the submitter s telephone number 1000A PER05 Communication Number Qualifier EM It is recommended that MAOs and other entities populate the submitter s email address 1000A PER Submitter EDI Contact Information N A N A 1000A PER07 Communication Number Qualifier FX It is recommended that MAOs and other entities populate the submitter s fax number 1000B NM1 Receiver Name N A N A 1000B NM102 Entity Type Qualifier 2 Non-Person Entity 1000B NM103 Receiver Name N A EDSCMS 1000B NM109 Receiver ID 80881 Identifies CMS as the receiver of the transaction and corresponds to the value in ISA08 Interchange Receiver ID. When the Payer ID must be changed for an encounter submitted to the EDS, MAOs and other entities must first void the original encounter, then submit a new encounter with the correct Payer ID.A 2010AA NM1 Billing Provider Name N A N A 2010AA NM108 Billing Provider ID Qualifier XX NPI Identifier 2010AA NM109 Billing Provider Identifier 1XXXXXXXXX Must be populated with a ten digit number, must begin with 1 Note: Default NPIs should only be submitted to the EDS when the 837 Institutional Companion Guide Version 38.0 July 2016. 15 LOOP ID REFERENCE NAME CODES NOTES COMMENTS provider is considered to be atypical. Institutional Default NPI: 1999999976 2010AA N4 Billing Provider City, State, Zip Code N A N A 2010AA N403 Zip Code N A The full nine (9) digits of the ZIP Code are required. If the last four (4) digits of the ZIP code are not available, populate a default value of 9998. 2010AA REF Billing Provider Tax Identification Number N A N A 2010AA REF01 Reference Identification Qualifier EI Employer s Identification Number (EIN) 2010AA REF02 Billing Provider Tax Identification Number XXXXXXXXX Must be populated with XXXXXXXXX. Note: Default EINs should only be submitted to the EDS when the provider is considered atypical. Institutional Default EIN: 199999997 2000B SBR Subscriber Information N A N A 2000B SBR01 Payer Responsibility Number Code S EDSCMS is considered the destination (secondary) payer 2000B SBR09 Claim Filing Indicator Code MA Must be populated with a value of MA Medicare Part A 2010BA NM1 Subscriber Name N A N A 2010BA NM108 Subscriber Id Qualifier MI Must be populated with a value of MI Member Identification Number 2010BA NM109 Subscriber Primary Identifier N A This is the subscriber s Health Insurance Claim (HIC) number. Must match the value in Loop 2330A, NM109 2010BB NM1 Payer Name N A N A 2010BB NM103 Payer Name N A EDSCMS 2010BB NM108 Payer ID Qualifier PI Must be populated with the value of PI Payer Identification 2010BB NM109 Payer Identification 80881 When the Payer ID must be changed for an encounter submitted to the EDS, MAOs and other entities must first void the original encounter, then submit a new encounter with the correct Payer ID. 2010BB N3 Payer Address N A N A 2010BB N301 Payer Address Line 7500 Security Blvd N A 837 Institutional Companion Guide Version 38.0 July 2016. 16 LOOP ID REFERENCE NAME CODES NOTES COMMENTS 2010BB N4 Payer City, State, ZIP Code N A N A 2010BB N401 Payer City Name Baltimore N A 2010BB N402 Payer State MD N A 2010BB N403 Payer ZIP Code 212441850 N A 2010BB REF Other Payer Secondary Identifier N A N A 2010BB REF01 Contract ID Identifier 2U N A 2010BB REF02 Contract ID Number N A MAO or other entities Contract ID Number 2300 CLM Claim Information N A N A 2300 CLM02 Total Claim Charge Amount N A N A 2300 CLM05-3 Claim Frequency Type Code 1 2 3 4 7 8 9 1 Original claim submission 2 Interim First Claim 3 Interim Continuing Claim 4 Interim Last Claim 7 Replacement 8 Void 9 Final Claim for a Home Health PPS Episode 2300 DTP Date Admission Date Hour N A N A 2300 DTP02 Date Time Period Format Qualifier D8 DT D8 CCYYMMDD DT CCYYMMDDHHMM 2300 DTP03 Admission Date Hour N A Hours (HH) are expressed as 00 for midnight, 01 for 1A.M., and so on through 23 for 11P.M. Minutes (MM) are expressed as 00 through 59. If the actual minutes are not known, use a default of 00. This is only required for original or final bills 2300 PWK Claim Supplemental Info N A N A 2300 PWK01 Report Type Code 09 OZ PY Populated for chart review submissions only Populated for encounters generated as a result of paper claims only Populated for encounters generated as a result of 4010 submission only 2300 PWK02 Attachment Transmission Code AA Populated for chart review, paper generated, and 4010 generated encounters 2300 CN1 Contract Information N A N A 2300 CN101 Contract Type Code 05 Populated for capitated staff model arrangements 2300 REF Payer Claim Control Number N A N A 2300 REF01 Original Reference Number F8 N A 837 Institutional Companion Guide Version 38.0 July 2016. 17 LOOP ID REFERENCE NAME CODES NOTES COMMENTS 2300 REF02 Payer Claim Control Number N A Identifies ICN from original encounter when submitting void or replacement EDR or chart review data EDR 2300 REF Medical Record Number N A N A 2300 REF01 Medical Record Identification Number EA N A 2300 REF02 Medical Record Identification Number 8 Chart review delete diagnosis code only submission Identifies the diagnosis code populated in Loop 2300, HI must be deleted from the encounter ICN in Loop 2300, REF02. 2300 NTE Claim Note N A N A 2300 NTE01 Note Reference Code ADD N A 2300 NTE02 Claim Note Text N A See Section 11.0 for the use and message requirements of default data information 2300 HI Value Information N A N A 2300 HI01-2 Value Code A0 Required on all ambulance encounters 2300 HI01-5 Value Code Amount N A If available, the ambulance pick-up location ZIP Code 4 should be provided. The ZIP code must be in the following format: XXXXXXX.XX (If a valid 4 cannot be populated, use 9998 as the 4 extension (XXXXX99.98)). 2320 SBR Other Subscriber Information N A N A 2320 SBR01 Payer Responsibility Sequence Number Code P T P Primary (when MAOs or other entities populate the payer paid amount) T Tertiary (when MAOs or other entities populate a true COB) 2320 SBR09 Claim Filing Indicator Code 16 Health Maintenance Organization (HMO) Medicare Risk 2330A NM1 Other Subscriber Name N A N A 2330A NM108 Identification Code Qualifier MI N A 2330A NM109 Subscriber Primary Identifier N A Must match the value in Loop 2010BA, NM109 2330B NM1 Other Payer Name N A N A 2330B NM108 Identification Code Qualifier XV N A 2330B NM109 Other Payer Primary Identifier Payer 01 MAO or other entity s Contract ID Number. Only populated if there is no Contract ID Number available for a true other payer 837 Institutional Companion Guide Version 38.0 July 2016. 18 LOOP ID REFERENCE NAME CODES NOTES COMMENTS 2330B N3 Other Payer Address N A N A 2330B N301 Other Payer Address Line N A MAO or other entity s address 2330B N4 Other Payer City, State, ZIP Code N A N A 2330B N401 Other Payer City Name N A MAO or other entity s City Name 2330B N402 Other Payer State N A MAO or other entity s State 2330B N403 Other Payer ZIP Code N A MAO or other entity s ZIP Code 2430 SVD Line Adjudication Information N A N A 2430 SVD01 Other Payer Primary Identifier N A Must match the value in Loop 2330B, NM109 2430 CAS Line Adjustments N A N A 2430 CAS02 Adjustment Reason Code N A If a service line is denied in the MAO s or other entity s adjudication system, the denial reason must be populated 2430 DTP Line Check or Remittance Date N A N A 2430 DTP03 N A N A Populate the claim receipt date minus one (1) day as the default primary payer adjudication date only in the instance that the primary payer adjudication date is not available 6.0 Acknowledgements and or Reports 6.1 TA1 Interchange Acknowledgement The TA1 report enables the receiver to notify the sender when there are problems with the interchange control structure. As the interchange envelope enters the EDFES, the EDI translator performs TA1 validation of the control segments envelope. The sender will only receive a TA1 there are syntax errors in the file. Errors found in this stage will cause the entire X12 interchange to be rejected with no further processing. MAOs and other entities will receive a TA1 interchange report acknowledging the syntactical inaccuracy of an X12 interchange header ISA and trailer IEA and the envelope s structure. Encompassed in the TA1 is the interchange control number, interchange date and time, interchange acknowledgement code, and interchange note code. The interchange control number, date, and time are identical to those populated on the original 837-I or 837-P ISA line, which allows for MAOs and other entities to associate the TA1 with a specific file previously submitted. Within the TA1 segment, MAOs and other entities will be able to determine if the interchange rejected by examining the interchange acknowledgement code (TA104) and the interchange note code (TA105). The interchange acknowledgement code stipulates whether the interchange (ISA IEA) rejected due to syntactical errors. An R will be the value in the TA104 data element if the interchange rejected due to syntactical errors. The interchange note code is a numeric code that notifies MAOs and other entities of the specific error. If a fatal error occurs, the EDFES generates and returns the TA1 interchange acknowledgement report within 24 hours of the interchange submission. If a TA1 interchange control 837 Institutional Companion Guide Version 38.0 July 2016. 19 structure error is identified, MAOs and other entities must correct the error and resubmit the interchange file. 6.2 999 Functional Group Acknowledgement After the interchange passes the TA1 edits, the next stage of editing is to apply Common Edits and Enhancements Module (CEM) edits and verify the syntactical accuracy of the functional group(s) (GS GE). Functional groups allow for organization of like data within an interchange; therefore, more than one (1) functional group containing multiple claims within the functional group can be populated in a file. The 999 acknowledgement report provides information on the validation of the GS GE functional group(s) and the consistency of the data. The 999 report provides MAOs and other entities information on whether the functional groups were accepted or rejected. If a file has multiple GS GE segments and errors occurred at any point within one (1) of the syntactical and IG level edit validations, the GS GE segment will reject, and processing will continue to the next GS GE segment. For instance, if a file is submitted with three (3) functional groups and there are errors in the second functional, the first functional group will accept, the second functional group will reject, and processing will continue to the third functional group. The 999 transaction set is designed to report on adherence to IG level edits and CMS standard syntax errors as depicted in the CMS 5010 Edits Spreadsheets. Three (3) possible acknowledgement values are: A Accepted R Rejected P Partially Accepted, At Least One (1) Transaction Set Was Rejected When viewing the 999 report, MAOs and other entities should navigate to the IK5 and AK9 segments. If an A is displayed in the IK5 and AK9 segments, the claim file is accepted and will continue processing. If an R is displayed in the IK5 and AK9 segments, an IK3 and an IK4 segment will be displayed. These segments indicate what loops and segments contain the error that requires correction so the interchange can be resubmitted. The third element in the IK3 segment identifies the loop that contains the error. The first element in the IK3 and IK4 indicates the segment and element that contain the error. The third element in the IK4 segment indicates the reason code for the error. 6.3 277CA Claim Acknowledgement After the file is accepted at the interchange and functional group levels, the third level of editing occurs at the transaction set level within the CEM in order to create the Claim Acknowledgement Transaction (277CA) report. The CEM checks the validity of the values within the data elements. For instance, data element N403 must be a valid nine (9)-digit ZIP code. If a non-existent ZIP code is populated, the CEM will reject the encounter. The 277CA is an unsolicited acknowledgement report from CMS to MAOs and other entities. The 277CA is used to acknowledge the acceptance or rejection of encounters submitted using a hierarchical level (HL) structure. The first level of hierarchical editing is at the Information Source level. This entity is the decision maker in the business transaction receiving the X12 837 transactions (EDSCMS). The next level is at the Information Receiver level. This is the entity expecting the response from the Information Source. The third hierarchal level is at the Billing Provider of Service level; and the fourth and final level is done at the Patient level. Acceptance or rejection at this level is based on the WPC and the CMS 5010 Edits Spreadsheets. Edits received at any hierarchical level will stop and no further editing will take place. For example, if there is a problem with the Billing Provider of Service 837 Institutional Companion Guide Version 38.0 July 2016. 20 submitted on the 837, individual patient edits will not be performed. For those encounters not accepted, the 277CA will detail additional actions required of MAOs and other entities in order to correct and resubmit those encounters. If an MAO or other entity receives a 277CA indicating that an encounter was rejected, the MAO or other entity must resubmit the encounter until the 277CA indicates no errors were found. If an encounter is accepted, the 277CA will provide the ICN assigned to that encounter. The ICN segment for the accepted encounter will be located in 2200D REF segment, REF01 IK and REF02 ICN. The ICN is a unique 13-digit number. If an encounter rejects, the 277CA will provide edit information in the STC segment. The STC03 data element will convey whether the HL structures accepted or rejected. The STC03 is populated with a value of WQ if the HL was accepted. If the STC03 data element is populated with a value of U, the HL is rejected and the STC01 data element will list the acknowledgement code. 6.4 MAO-001 Encounter Data Duplicates Report When the MAO-002 Encounter Data Processing Status Report is returned to an MAO or other entity, and contains one or more the following edits, 98300 Exact Inpatient Duplicate Encounter, 98315 Linked Chart Review Duplicate, 98320 Chart Review Duplicate, or 98325 Service Line(s) Duplicated, the EDPS will also generate and return the MAO-001 Encounter Data Duplicates Report. MAOs and other entities will not receive the MAO-001 report if there are no duplicate errors received on submitted encounters. The MAO-001 report is a fixed length report available in flat file and formatted report layouts. It provides information for encounters and service lines that receive a status of reject and specific error messages 98300, 98315, 98320, or 98325. MAOs and other entities must correct and resubmit only those encounters that received edits 98300, 98315, 98320, or 98325. The MAO-001 report allows MAOs and other entities the opportunity to more easily reconcile these duplicate encounters and service lines. 6.5 MAO-002 Encounter Data Processing Status Report After a file accepts through the EDFES, the file is transmitted to the Encounter Data Processing System (EDPS) where further editing, processing, pricing, and storage occurs. As a result of EDPS editing, the EDPS will return the MAO-002 Encounter Data Processing Status Report. The MAO-002 report is a fixed length report available in flat file and formatted report layouts that provide encounter and service line level information. The MAO-002 reflects two (2) statuses at the encounter and service line level: accepted or rejected. Lines that reflect a status of accept yet contain an error message in the Error Description column are considered informational edits. MAOs and other entities are not required to take further action on informational edits; however, they are encouraged to do so to ensure accuracy of internal claims processing data. The 000 line on the MAO-002 report identifies the header level and indicates either accepted or rejected status. If the 000 header line is rejected, the encounter is considered rejected and MAOs 837 Institutional Companion Guide Version 38.0 July 2016. 21 and other entities must correct and resubmit the encounter. If the 000 header line is accepted and at least one (1) other line (i.e., 001 002 003 004) is accepted, then the overall encounter is accepted. 6.6 Reports File Naming Conventions In order for MAOs and other entities to receive and identify the EDFES Acknowledgement Reports (TA1, 999 and 277CA) and EDPS MAO-002 Encounter Data Processing Status Reports, specific reports file naming conventions have been used. The file name ensures that the specific reports are appropriately distributed to each secure, unique mailbox. The EDFES and EDPS have established unique file naming conventions for reports distributed during testing and production. 6.6.1 Testing Reports File Naming Convention Table 5 below provides the EDFES reports file naming conventions according to connectivity method. MAOs and other entities should note that Connect:Direct (NDM) users reports file naming conventions are user defined. 837 Institutional Companion Guide Version 38.0 July 2016. 22 TABLE 5 TESTING EDFES REPORTS FILE NAMING CONVENTIONS REPORT TYPE GENTRAN TIBCO MAILBOX FTP MAILBOX EDFES Notifications T.xxxxx.EDS_RESPONSE.pn RSPxxxxx.RSP.REJECTED_ID TA1 T.xxxxx.EDS_REJT_IC_ISAIEA.pn X12xxxxx.X12.TMMDDCCYYHHMMS 999 T.xxxxx.EDS_REJT_FUNCT_TRANS.pn 999.999.999 999 T.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn 999.999.999 277CA T.xxxxx.EDS_RESP_CLAIM_NUM.pn RSPxxxxx.RSP_277CA Table 6 below provides the EDPS reports file naming conventions by connectivity method. MAOs and other entities should note that Connect:Direct (NDM) users reports file naming conventions are user defined. TABLE 6 TESTING EDPS REPORTS FILE NAMING CONVENTIONS Table 7 below provides a description of the file name components, which will assist MAOs and other entities in identifying the report types. TABLE 7 FILE NAME COMPONENT DESCRIPTION FILE NAME COMPONENT DESCRIPTION RSPxxxxx The type of data RSP and a sequential number assigned by the server xxxxx X12xxxxx The type of data X12 and a sequential number assigned by the server xxxxx TMMDDCCYYHHMMS The Date and Time stamp the file was processed 999xxxxx The type of data 999 and a sequential number assigned by the server xxxxx RPTxxxxx The type of data RPT and a sequential number assigned by the server xxxxx EDPS_XXX Identifies the specific EDPS Report along with the report number (i.e., 002, etc.) XXXXXXX Seven (7) characters available to be used as a short description of the contents of the file RPT FILE Identifies if the file is a formatted report RPT or a flat file FILE layout 6.6.2 Production Reports File Naming Convention A different production reports file naming convention is used so that MAOs and other entities may easily identify reports generated and distributed during production. Table 8 below provides the reports file naming conventions per connectivity method for production reports. CONNECTIVITY METHOD TESTING NAMING CONVENTION FORMATTED REPORT TESTING NAMING CONVENTION FLAT FILE LAYOUT GENTRAN TIBCO T.xxxxx.EDPS_001_DataDuplicate_Rpt T.xxxxx.EDPS_002_DataProcessingStatus_Rpt T.xxxxx.EDPS_004_RiskFilter_Rpt T.xxxxx.EDPS_005_DispositionSummary_Rpt T.xxxxx.EDPS_006_EditDisposition_Rpt T.xxxxx.EDPS_007_DispositionDetail_Rpt T.xxxxx.EDPS_001_DataDuplicate_File T.xxxxx.EDPS_002_DataProcessingStatus_File T.xxxxx.EDPS_004_RiskFilter_File T.xxxxx.EDPS_005_DispositionSummary_ File T.xxxxx.EDPS_006_EditDisposition_ File T.xxxxx.EDPS_007_DispositionDetail_ File FTP RPTxxxxx.RPT.EDPS_001_DATDUP_RPT RPTxxxxx.RPT.EDPS_002_DATPRS_RPT RPTxxxxx.RPT.EDPS_004_RSKFLT_RPT RPTxxxxx.RPT.EDPS_005_DSPSUM_RPT RPTxxxxx.RPT.EDPS_006_EDTDSP_RPT RPTxxxxx.RPT.EDPS_007_DSTDTL_RPT RPTxxxxx.RPT.EDPS_001_DATDUP_File RPTxxxxx.RPT.EDPS_002_DATPRS_File RPTxxxxx.RPT.EDPS_004_RSKFLT_ File RPTxxxxx.RPT.EDPS_005_DSPSUM_ File RPTxxxxx.RPT.EDPS_006_EDTDSP_ File RPTxxxxx.RPT.EDPS_007_DSTDTL_ File 837 Institutional Companion Guide Version 38.0 July 2016. 23 TABLE 8 PRODUCTION EDFES REPORTS FILE NAMING CONVENTIONS 1. File Name Record 3. File Count Record REPORT TYPE GENTRAN TIBCO MAILBOX FTP MAILBOX EDFES Notifications P.xxxxx.EDS_RESPONSE.pn RSPxxxxx.RSP.REJECTED_ID TA1 P.xxxxx.EDS_REJT_IC_ISAIEA.pn X12xxxxx.X12.TMMDDCCYYHHMMS 999 P.xxxxx.EDS_REJT_FUNCT_TRANS.pn 999.999.999 999 P.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn 999.999.999 277CA P.xxxxx.EDS_RESP_CLAIM_NUM.pn RSPxxxxx.RSP_277CA Table 9 below provides the production EDPS reports file naming conventions per connectivity method. TABLE 9 PRODUCTION EDPS REPORTS FILE NAMING CONVENTIONS 6.7 EDFES Notifications The EDFES distributes special notifications to submitters when encounters have been processed by the EDFES, but will not proceed to the EDPS for further processing. These notifications are distributed to MAOs and other entities, in addition to standard EDFES Acknowledgement Reports (TA1, 999, and 277CA) in order to avoid returned, unprocessed files from the EDS. Table 10 provides the file type, EDFES notification message, and EDFES notification message description. The file has an 80 character record length and contains the following record layout: a. Positions 1 7 Blank Spaces b. Positions 8 18 File Name: c. Positions 19 62 Name of the Saved File d. Positions 63 80 Blank Spaces 2. File Control Record a. Positions 1 4 Blank Spaces b. Positions 5 18 File Control: c. Positions 19 27 File Control Number d. Positions 28 80 Blank Spaces a. Positions 1 18 Number of Claims: CONNECTIVITY METHOD PRODUCTION NAMING CONVENTION FORMATTED REPORT PRODUCTION NAMING CONVENTION FLAT FILE LAYOUT GENTRAN TIBCO P.xxxxx.EDPS_001_DataDuplicate_Rpt P.xxxxx.EDPS_002_DataProcessingStatus_Rpt P.xxxxx.EDPS_004_RiskFilter_Rpt P.xxxxx.EDPS_005_DispositionSummary_Rpt P.xxxxx.EDPS_006_EditDisposition_Rpt P.xxxxx.EDPS_007_DispositionDetail_Rpt P.xxxxx.EDPS_001_DataDuplicate_File P.xxxxx.EDPS_002_DataProcessingStatus_File P.xxxxx.EDPS_004_RiskFilter_File P.xxxxx.EDPS_005_DispositionSummary_ File P.xxxxx.EDPS_006_EditDisposition_ File P.xxxxx.EDPS_007_DispositionDetail_ File FTP RPTxxxxx.RPT.PROD_001_DATDUP_RPT RPTxxxxx.RPT.PROD_002_DATPRS_RPT RPTxxxxx.RPT.PROD_004_RSKFLT_RPT RPTxxxxx.RPT.PROD_005_DSPSUM_RPT RPTxxxxx.RPT.PROD_006_EDTDSP_RPT RPTxxxxx.RPT.PROD_007_DSTDTL_RPT RPTxxxxx.RPT.PROD_001_DATDUP_File RPTxxxxx.RPT.PROD_002_DATPRS_File RPTxxxxx.RPT.PROD_004_RSKFLT_ File RPTxxxxx.RPT.PROD_005_DSPSUM_ File RPTxxxxx.RPT.PROD_006_EDTDSP_ File RPTxxxxx.RPT.PROD_007_DSTDTL_ File 837 Institutional Companion Guide Version 38.0 July 2016. 24 b. Positions 19 24 File Claim Count c. Positions 25 80 Blank Spaces 4. File Separator Record a. Positions 1 80 Separator (----------) 5. File Message Record a. Positions 1 80 FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S) 6. File Message Records a. Positions 1 80 File Message The report format example is as follows: FILE NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX FILE CONTROL: XXXXXXXXX NUMBER OF CLAIMS: 99,999 FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S) XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Table 10 provides the complete list of testing and production EDFES notification messages. TABLE 10 EDFES NOTIFICATIONS APPLIES TO NOTIFICATION MESSAGE NOTIFICATION MESSAGE DESCRIPTION All files submitted FILE ID (XXXXXXXXX) IS A DUPLICATE OF A FILE ID SENT WITHIN THE LAST 12 MONTHS The file ID must be unique for a 12 month period All files submitted SUBMITTER NOT AUTHORIZED TO SEND CLAIMS FOR PLAN (CONTRACT ID) The submitter is not authorized to send for this plan All files submitted PLAN ID CANNOT BE THE SAME AS THE SUBMITTER ID The Contract ID cannot be the same as the Submitter ID All files submitted AT LEAST ONE ENCOUNTER IS MISSING A CONTRACT ID IN THE 2010BB-REF02 SEGMENT The Contract ID is missing Production files submitted SUBMITTER NOT CERTIFIED FOR PRODUCTION The submitter must be certified to send encounters for production Tier 2 files submitted THE INTERCHANGE USAGE INDICATOR MUST EQUAL T The Institutional Tier 2 file is being sent with a P in the ISA15 field Tier 2 files submitted PLAN (CONTRACT ID) HAS (X,XXX) CLAIMS IN THIS FILE. ONLY 2,000 ARE ALLOWED The number of encounters for a Contract ID cannot be greater than 2,000 End-to-End Testing FILE CANNOT CONTAIN MORE THAN 6 ENCOUNTERS The number of encounters cannot be greater than 6 End-to-End Testing PATIENT CONTROL NUMBER IS MORE THAN 20 CHARACTERS LONG THE TC WAS TRUNCATED The Claim Control Number, including the Test Case Number, must not exceed 20 characters End-to-End Testing FILE CONTAINS (X) TEST CASE (X) ENCOUNTER(S) The file must contain two (2) of each test case Test NO TEST CASES FOUND IN THIS FILE This file was processed with the Interchange Usage Indicator T and the Submitter is not yet Certified 837 Institutional Companion Guide Version 38.0 July 2016. 25 APPLIES TO NOTIFICATION MESSAGE NOTIFICATION MESSAGE DESCRIPTION End-to-End Testing ADDITIONAL FILES CANNOT BE VALIDATED UNTIL AN MAO-002 REPORT HAS BEEN RECEIVED The MAO-002 report must be received before additional files can be submitted All files submitted FILE CANNOT EXCEED 5,000 ENCOUNTERS The maximum number of encounters allowed in a file All files submitted TRANSACTION SET (ST SE) (XXXXXXXXX) CANNOT EXCEED 5,000 CLAIMS There can only be 5,000 claims in each ST SE Loop All files submitted DATE OF SERVICE CANNOT BE BEFORE 2011 Files cannot be submitted with a date of service before 2011 All files submitted CAS ADJUSTMENT AMOUNT MUST NOT BE 0 The CAS Adjustment Amount cannot be zero (0). All files submitted BILLING PROVIDER LOOP IS MISSING The Billing Provider Loop must be present. 7.0 Front-End Edits CMS provides a list of the edits used to process all encounters submitted to the EDFES. The CMS 5010 Institutional Edits Spreadsheet identifies currently active and deactivated edits for MAOs and other entities to reference for programming their internal systems and reconciling EDFES Acknowledgement Reports. The CMS 5010 Institutional Edits Spreadsheet provides documentation regarding edit rules that explain how to identify an EDFES edit and the associated logic. The CMS 5010 Institutional Edits Spreadsheet also provides a change log that lists the revision history for edit updates. MAOs and other entities are able to access the CMS 5010 Institutional Edits Spreadsheet on the CMS website at: https: www.cms.gov Regulations-and-Guidance Guidance Transmittals 1. Select the current year in the left navigation column (e.g., 2015 Transmittals) 2. Key in 'EDI Front End Updates' in the 'Filter On' box 3. Select the most current transmittal to obtain the latest versions of the CEM Edits Spreadsheets 4. Click on the link(s) under 'Downloads' at the bottom of the page 7.1 Deactivated Front-End Edits Several CEM edits currently active in the CMS 5010 Institutional Edits Spreadsheet will be deactivated in order to ensure that syntactically correct encounters pass front-edit editing. Table 11 provides a list of the deactivated EDFES CEM edits. The edit reference column provides the exact reference for the deactivated edits. The edit description column provides the Claim Status Category Code (CSCC), the Claim Status Code (CSC), and the Entity Identifier Code (EIC), when applicable. The notes column provides a description of the edit reason. MAOs and other entities should reference the WPC website at www.wpc-edi.com for a complete listing of all CSCCs and CSCs. 837 Institutional Companion Guide Version 38.0 July 2016. 26 TABLE 11 837 INSTITUTIONAL DEACTIVATED EDFES EDITS EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.084.2010AA.NM109.050 CSCC A8: "Acknowledgement Rejected for relational field in error" CSC 496 "Submitter not approved for electronic claim submissions on behalf of this entity." EIC: 85 Billing Provider This Fee for Service edit validates the NPI and submitter ID number to ensure the submitter is authorized to submit on the provider s behalf. Encounter data cannot use this validation as we validate the plan number and submitter ID to ensure the submitter is authorized to submit on the plan s behalf. 2010AA.NM109 billing provider must be "associated" to the submitter (from a trading partner management perspective) in 1000A.NM109. X223.087.2010AA.N301.070 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 503: "Entity's Street Address" EIC: 85 Billing Provider Remove edit check for 2010AA N3 PO Box variations when ISA08 80881 (Institutional Payer Code). X223.084.2010AA.NM109.040 CSCC A8: "Acknowledgement Rejected for relational field in error." CSC 562: "Entity's National Provider Identifier (NPI)" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.NM109 must be a valid NPI on the Crosswalk when evaluated with 1000B.NM109. X223.090.2010AA.REF02.050 CSCC A8: "Acknowledgement Rejected for relational field in error" CSC 562: "Entity's National Provider Identifier (NPI)" CSC 128: "Entity's tax id" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.REF must be associated with the provider identified in 2010AA.NM109. X223.127.2010BB.REF.010 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 732: "Information submitted inconsistent with billing guidelines." CSC 560: "Entity's Additional Secondary Identifier." EIC: PR "Payer" This REF Segment is used to capture the Plan number as this is unique to encounter data submission only. The CEM applies the following logic: Non-VA claims: 2010BB.REF with REF01 "2U", "EI", "FY" or "NF" must not be present. VA claims: 2010BB.REF with REF01 "EI", "FY" or "NF" must not be present. This edit needs to remain off in order for the submitter to send in his plan number. X223.424.2400.SV202-7.025 CSCC A8: "Acknowledgement Rejected for relational field in error" CSC 306 Detailed description of service 2400.SV202-7 must be present when 2400.SV202-2 contains a non-specific procedure code. When using a not otherwise classified or generic HCPCS procedure code the CEM is editing for a more descriptive meaning of the procedure code. For example, the submitter is using J3490. The description for this HCPCS is Not Otherwise Classified (NOC) Code. 837 Institutional Companion Guide Version 38.0 July 2016. 27 EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.153.2300.CL103.015 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 234: "Patient discharge status" When 2300.CL103 value 20, 40, 41, or 42 is present, at least one occurrence of 2300.HI01-2 thru HI12-2 must 55 where HI01-1 is BH. X223.424.2400.SV203.060 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 400: "Claim is out of balance: CSC 583:"Line Item Charge Amount" CSC 643: "Service Line Paid Amount" SV203 must the sum of all payer amounts paid found in 2430 SVD02 and the sum of all line adjustments found in 2430 CAS Adjustment Amounts. X223.143.2300.CLM02.070 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 400: "Claim is out of balance" CSC 178: "Submitted Charges" 2300.CLM02 must the sum of all 2400.SV203 amounts. X223.143.2300.CLM02.080 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 400: "Claim is out of Balance" CSC 672 "Payer's payment information is out of balance CLM02 must equal the sum of all 2320 CAS amounts and all 2430 CAS amounts and 2320 AMT02 (when AMT01 D). X223.389.2330B.DTP.030 IK304 | /kaggle/input/edi-db-835-837/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_0 |
Encounter data cannot use this validation as we validate the plan number and submitter ID to ensure the submitter is authorized to submit on the plan s behalf. 2010AA.NM109 billing provider must be "associated" to the submitter (from a trading partner management perspective) in 1000A.NM109. X223.087.2010AA.N301.070 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 503: "Entity's Street Address" EIC: 85 Billing Provider Remove edit check for 2010AA N3 PO Box variations when ISA08 80881 (Institutional Payer Code). X223.084.2010AA.NM109.040 CSCC A8: "Acknowledgement Rejected for relational field in error." CSC 562: "Entity's National Provider Identifier (NPI)" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.NM109 must be a valid NPI on the Crosswalk when evaluated with 1000B.NM109. X223.090.2010AA.REF02.050 CSCC A8: "Acknowledgement Rejected for relational field in error" CSC 562: "Entity's National Provider Identifier (NPI)" CSC 128: "Entity's tax id" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.REF must be associated with the provider identified in 2010AA.NM109. X223.127.2010BB.REF.010 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 732: "Information submitted inconsistent with billing guidelines." CSC 560: "Entity's Additional Secondary Identifier." EIC: PR "Payer" This REF Segment is used to capture the Plan number as this is unique to encounter data submission only. The CEM applies the following logic: Non-VA claims: 2010BB.REF with REF01 "2U", "EI", "FY" or "NF" must not be present. VA claims: 2010BB.REF with REF01 "EI", "FY" or "NF" must not be present. This edit needs to remain off in order for the submitter to send in his plan number. X223.424.2400.SV202-7.025 CSCC A8: "Acknowledgement Rejected for relational field in error" CSC 306 Detailed description of service 2400.SV202-7 must be present when 2400.SV202-2 contains a non-specific procedure code. When using a not otherwise classified or generic HCPCS procedure code the CEM is editing for a more descriptive meaning of the procedure code. For example, the submitter is using J3490. The description for this HCPCS is Not Otherwise Classified (NOC) Code. 837 Institutional Companion Guide Version 38.0 July 2016. 27 EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.153.2300.CL103.015 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 234: "Patient discharge status" When 2300.CL103 value 20, 40, 41, or 42 is present, at least one occurrence of 2300.HI01-2 thru HI12-2 must 55 where HI01-1 is BH. X223.424.2400.SV203.060 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 400: "Claim is out of balance: CSC 583:"Line Item Charge Amount" CSC 643: "Service Line Paid Amount" SV203 must the sum of all payer amounts paid found in 2430 SVD02 and the sum of all line adjustments found in 2430 CAS Adjustment Amounts. X223.143.2300.CLM02.070 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 400: "Claim is out of balance" CSC 178: "Submitted Charges" 2300.CLM02 must the sum of all 2400.SV203 amounts. X223.143.2300.CLM02.080 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 400: "Claim is out of Balance" CSC 672 "Payer's payment information is out of balance CLM02 must equal the sum of all 2320 CAS amounts and all 2430 CAS amounts and 2320 AMT02 (when AMT01 D). X223.389.2330B.DTP.030 IK304 2: "Unexpected Segment" If 2430 DTP with 573 is present, then 2330B DTP must not be present. 837 Institutional Companion Guide Version 38.0 July 2016. 28 7.2 Temporarily Deactivated Front-End Edits Table 12 provides a list of the temporarily deactivated EDFES Institutional CEM balancing edits in order to ensure that encounters that require balancing of monetary fields will pass front-end editing. Note: The Institutional edits listed in Table 12 are not all-inclusive and are subject to amendment. TABLE 12 837 INSTITUTIONAL TEMPORARILY DEACTIVATED EDFES EDITS EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.364.2320.AMT.040 CSCC A7: Acknowledgement Rejected for Invalid Information CSC 41: Special handling required at payer site CSC 286: Other Payer's Explanation of Benefits payment information CSC 732: Information submitted inconsistent with billing guidelines N A X223.109.2000B.SBR03.004 X223.109.2000B.SBR03.006 CSCC A8: Acknowledgement Rejected for relational field in error CSC 163: Entity s Policy Number CSC 732: Information submitted inconsistent with billing guidelines EIC IL: Subscriber N A X223.109.2000B.SBR04.004 X223.109.2000B.SBR04.007 CSCC A8: Acknowledgement Rejected for relational field in error CSC 663: Entity's Group Name CSC 732: Information submitted inconsistent with billing guidelines EIC IL: Subscriber N A 7.3 New EDFES Edits Table 13 provides a list of EDFES Institutional CEM edits recently added or revised that may impact encounter processing. TABLE 13 837 NEW INSTITUTIONAL EDFES EDITS Note: Table 13 will not be provided when there are no relevant enhancements implemented for the current release of the CMS EDS Companion Guides. 8.0 Duplicate Logic In order to ensure encounters submitted are not duplicates of encounters previously submitted, the EDS will perform header and detail level duplicate checking. If the header and or detail level duplicate checking determines that the file is a duplicate, the file will reject, and an error report will be returned to the submitter. 837 Institutional Companion Guide Version 38.0 July 2016. 29 8.1 Header Level When a file (ISA IEA) is received, the system assigns a hash total to the file based on the entire ISA IEA interchange. The EDS uses hash totals to ensure the accuracy of processed data. The hash total is a total of several fields or data in a file, including fields not normally used in calculations, such as the account number. At various stages in processing, the hash total is recalculated and compared with the original. If a file comes in later in a different submission, or a different submission of the same file, and gets the same hash total, it will reject as a duplicate. In addition to the hash total, the system also references the values collectively populated in ISA13, GS06, ST02, and BHT03. If two (2) files are submitted with the exact same values populated as a previously submitted and accepted file, the file will be considered a duplicate and the error message CSCC - A8 Acknowledgement Rejected for relational field in error, CSC -746 Duplicate Submission will be provided on the 277CA. 8.2 Detail Level Once an encounter is processed in the EDPS, it is stored in an internal repository, the Encounter Operational Data Store (EODS). If a new encounter is submitted that matches specific values on another stored encounter, the encounter will reject as a duplicate encounter. The encounter will be returned to the submitter with an error message identifying it as a duplicate encounter. Currently, the following values are the minimum set of items used for matching an encounter in the EODS: Beneficiary Demographic o Health Insurance Claim Number (HICN) Date of Service Type of Bill (TOB) Revenue Code(s) Procedure Code(s) and up to 4 modifiers Billing Provider NPI Charge (Billed) Amount Paid Amount (as populated at both the Header and Detail Levels) Paid Amounts by the MAO and other entity will only be used in the duplicate validation logic. 9.0 837 Institutional Business Cases In accordance with 45 CFR 160.103 of the HIPAA, Protected Health Information (PHI) is not included in the 837-I business cases. As a result, the business cases have been populated with fictitious information about the Subscriber, MAO, and provider(s). The business cases reflect 2012 dates of service. Although the business cases are provided as examples of possible encounter submissions, MAOs and other entities must populate valid data in order to successfully pass translator and CEM level editing. MAOs and other entities should direct questions regarding the contents of the EDS Test Case Specification to encounterdata cms.hhs.gov. Note: The business cases identified in the CMS EDS 837-I Companion Guide indicate paid amounts and DTP segments at the line level. 837 Institutional Companion Guide Version 38.0 July 2016. 30 The Adjudication or Payment Date (DTP 573 segment) must follow the paid amount. For example, if the paid amount is populated at the claim level, the DTP 573 segment must be populated at the claim level. If the paid amount is populated at the line level, the DTP 573 segment must be populated at the line level. 837 Institutional Companion Guide Version 38.0 July 2016. 31 9.1 Standard Institutional Encounter Business Scenario 1: Patient subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Happy Health Plan was the MAO. Mercy Hospital diagnosed Mary with Congestive Health Failure as the primary diagnosis and diabetes as an additional diagnosis. File String 1: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 200.00 11:A:1 A Y Y DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 HI BK:4280 HI BJ:4280 HI BF:25000 HI BR:3121:D8:20120330 HI BH:41:D8:20110501 BH:27:D8:20110715 BH:33:D8:20110718 BH:C2:D8:20110729 HI BE:30:::20 HI BG:01 NM1 71 1 JONES AMANDA AL XX 1005554104 837 Institutional Companion Guide Version 38.0 July 2016. 32 SBR P 18 XYZ1234567 16 AMT D 200.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0300 HC:81099 200.00 UN 1 DTP 472 D8 20120330 SVD H9999 200.00 HC:81099 0300 1 DTP 573 D8 20120401 SE 50 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 33 9.2 Capitated Institutional Encounter Business Scenario 2: Patient subscriber, Mary Dough, is enrolled in Happy Health Plan and went to Mercy Hospital because she was experiencing leg pain. Mercy Hospital diagnosed Mary with diabetes and leg pain. Happy Health Plan has a capitated arrangement with Mercy Hospital. Note: For Institutional EDRs, the indicator of whether a record is capitated occurs at the header level. In the event that the MAO has a contractual arrangement with a provider under which certain services are paid on a FFS basis and other services are paid on capitated basis, the MAO should submit as a single EDR with the CN101(Contract Type Code) at the header level in LOOP 2300 left blank and populate the CAS segment at the line level within LOOP 2430 with a Group Reason Code of 24 to indicate a capitated service line. For FFS lines, the Group Reason Code should be populated using the codes submitted by the provider on the 835. If all lines in an institutional EDR are capitated, then the EDR should be submitted with the CN101(Contract Type Code) at the header level in LOOP 2300 set to 05. File String 2: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000331 1 P: GS HC ENH9999 80881 20120816 1144 30 X 005010X223A2 ST 837 0021 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 0.00 11:A:1 A Y Y 837 Institutional Companion Guide Version 38.0 July 2016. 34 DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 CN1 05 HI BK:4280 HI BJ:4280 HI BF:25000 HI BR:3121:D8:20120330 HI BH:41:D8:20110501 BH:27:D8:20110715 BH:33:D8:20110718 BH:C2:D8:20110729 HI BE:30:::20 HI BG:01 NM1 71 1 JONES AMANDA AL XX 1005554104 SBR P 18 XYZ1234567 ZZ AMT D 100.50 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 LX 1 SV2 0300 HC:81099 0.00 UN 1 DTP 472 D8 20120330 SVD H9999 100.50 HC:81099 0300 1 CAS CO 24 -100.50 DTP 573 D8 20120401 SE 50 0021 GE 1 30 IEA 1 000000331 837 Institutional Companion Guide Version 38.0 July 2016. 35 9.3 Chart Review Institutional Encounter No Linked ICN Business Scenario 3: Patient subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Happy Health Plan performs a chart review at Mercy Hospital and determines that a diagnosis for Mary Dough was never submitted on a claim. The medical record does not contain enough information to submit a full claim, yet there is enough information to support the diagnosis and link the chart review encounter back to the medical record. Happy Health Plan submits a chart review encounter with no linked ICN to add the diagnosis. File String 3: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999899 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 0.00 11:A:1 A Y Y DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 PWK 09 AA HI BK:4280 HI BJ:4280 HI BF:25000 HI BR:3121:D8:20120330 HI BH:41:D8:20110501 BH:27:D8:20110715 BH:33:D8:20110718 BH:C2:D8:20110729 837 Institutional Companion Guide Version 38.0 July 2016. 36 HI BE:30:::20 HI BG:01 NM1 71 1 JONES AMANDA AL XX 1005554104 SBR P 18 XYZ1234567 16 AMT D 0.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0300 HC:81099 0.00 UN 1 SVD H9999 65.00 HC:81099 1 DTP 472 D8 20120330 SE 49 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 37 9.4 Chart Review Institutional Encounter Linked ICN (Add Diagnoses) Business Scenario 4: Patient subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Mercy Hospital submits the encounter to CMS and receives an ICN of 1294598098746. Happy Health Plan performs a chart review related to ICN 1294598098746 and determines that additional diagnoses were not originally reported for diabetes and high cholesterol. Note: In the event that a linked chart review encounter requires the addition and deletion of multiple diagnosis codes, MAOs should submit a single linked chart review encounter (2300 CLM05-3 1 (Original)) to add all necessary diagnoses, and submit a separate linked chart review encounter (also 2300 CLM05-3 1 (Original)) to delete all necessary diagnosis codes. MAOs should submit a replacement chart review encounter (2300 CLM05-3 7 ) only in the event previously stored chart review data should be completely replaced. MAOs should submit a void chart review encounter (2300 CLM05-3 8 ) only when the original chart review encounter (linked or unlinked) requires deletion. File String 4: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999899 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 0.00 11:A:1 A Y Y DTP 096 TM 0958 837 Institutional Companion Guide Version 38.0 July 2016. 38 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 PWK 09 AA REF F8 1294598098746 HI BK:25000 (First diagnosis to be added, BK not repeatable) HI BF:2720 (Second diagnosis to be added, BF repeatable through HI12) NM1 71 1 JONES AMANDA AL XX 1005554106 SBR P 18 XYZ1234567 16 AMT D 0.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0300 HC:81099 0.00 UN 1 SVD H9999 87.50 HC:81099 1 DTP 472 D8 20120330 SE 50 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 39 9.5 Chart Review Institutional Encounter Linked ICN (Delete Diagnoses) Business Scenario 5: Patient subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Happy Health Plan submits the encounter to CMS and receives an ICN of 1294598098746. Happy Health Plan performs a chart review related to ICN 1294598098746 and determines that the original encounter should not have reported diagnoses related to diabetes and high cholesterol, which should be deleted. Happy Health Plan submits a Chart Review encounter to delete the relevant diagnoses. Note: In the event that a linked chart review encounter requires the addition and deletion of multiple diagnosis codes, MAOs should submit a single linked chart review encounter (2300 CLM05-03 1 (Original)) to add all necessary diagnoses, and submit a separate linked chart review encounter (also 2300 CLM05-03 1 (Original)) to delete all necessary diagnosis codes. MAOs should submit a replacement chart review encounter (2300 CLM05-03 7 ) only in the event previously stored chart review data should be completely replaced. MAOs should submit a void chart review encounter (2300 CLM05-3 8 ) only when the original chart review encounter (linked or unlinked) requires deletion. File String 5: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999899 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 0.00 11:A:1 A Y Y 837 Institutional Companion Guide Version 38.0 July 2016. 40 DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 PWK 09 AA REF F8 1294598098746 REF EA 8 HI BK:25000 (First diagnosis to be deleted, BK not repeatable) HI BF:2720 (Second diagnosis to be deleted, BF repeatable through HI12) NM1 71 1 JONES AMANDA AL XX 1005554106 SBR P 18 XYZ1234567 16 AMT D 0.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0300 HC:81099 0.00 UN 1 SVD H9999 87.50 HC:81099 1 DTP 472 D8 20120330 SE 50 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 41 9.6 Complete Replacement Institutional Encounter Business Scenario 6: Patient subscriber, Mary Dough, went to Mercy Hospital because she was experiencing heart pain. Mercy Hospital diagnosed Mary with Congestive Heart Failure and diabetes. Happy Health Plan submits the encounter to CMS and receives an ICN 1122978564098. After further investigation, it was determined that Happy Health Plan submitted the encounter with an incorrect payment. Happy Health Plan submits a replacement encounter to CMS, using ICN 1122978564098 to correct the payment amount. File String 6: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000554 1 P: GS HC ENH9999 80881 20120816 1144 80 X 005010X223A2 ST 837 0567 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 200.00 11:A:7 A Y Y DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330-20120331 CL1 2 9 01 REF F8 1222978564098 HI BK:4280 HI BJ:4280 HI BR:3121:D8:20120330 HI BH:41:D8:20110501 BH:27:D8:20110715 BH:33:D8:20110718 BH:C2:D8:20110729 HI BE:30:::20 837 Institutional Companion Guide Version 38.0 July 2016. 42 HI BG:01 NM1 71 1 JOHNSON AMANDA AL XX 1005554104 SBR P 18 XYZ1234567 16 CAS CO 39 120.00 AMT D 80.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235048769 LX 1 SV2 0300 HC:81099 200.00 UN 1 DTP 472 D8 20120330 SVD H9999 0.00 HC:99212 1 DTP 573 20120401 SE 50 0567 GE 1 80 IEA 1 000000554 837 Institutional Companion Guide Version 38.0 July 2016. 43 9.7 Complete Deletion Institutional Encounter Business Scenario 7: Patient subscriber, Mary Dough, was admitted to Miracle Health Center because she was experiencing abdominal pain. Happy Health Plan is the MAO. Dr. Smart at Miracle Health Center diagnosed Mary with a gastric ulcer. Happy Health Plan submits the encounter to CMS and receives ICN 1212487000032. Happy Health Plan then determines that the claim for Mary s visit was not adjudicated in their internal system. Happy Health Plan submits a void encounter to delete the previously submitted encounter. File String 7: ISA 00 00 ZZ ENH9999 ZZ 80881 120430 114 4 00501 000000298 1 P: GS HC ENH9999 80881 20120430 1144 82 X 005010X222A1 ST 837 0290 005010X222A1 BHT 0019 00 3920394930206 20120428 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 1 MIRACLE HEALTH CENTER XX 1299999999 N3 123 CENTRAL DRIVE N4 NORFOLK VA 235139999 REF EI 765879876 PER IC ELIZABETH SMART TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 47 MB NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 2997677856479709654A 100.50 11:B:8 Y A Y Y REF F8 1212487000032 HI BK:53190 SBR P 18 XYZ1234567 16 CAS CO 223 100.50 AMT D 0.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 837 Institutional Companion Guide Version 38.0 July 2016. 44 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 HC:99212 100.50 UN 1 1 DTP 472 D8 20120401 SVD H9999 0.00 HC:99212 1 DTP 573 D8 20120403 SE 41 0290 GE 1 82 IEA 1 000000298 837 Institutional Companion Guide Version 38.0 July 2016. 45 9.8 Atypical Provider Institutional Encounter Business Scenario 8: Patient subscriber, Mary Dough, receives personal care services from an atypical provider. Happy Health Plan was the MAO. File String 8: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000032 1 P: GS HC ENH9999 80881 20120816 1144 35 X 005010X223A2 ST 837 0039 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY SERVICES XX 1999999976 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 199999997 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578799A 50.00 83:A:1 A Y Y DTP 434 RD8 20120330-20120331 CL1 9 9 01 HI BK:78099 NTE ADD 048052 SBR P 18 XYZ1234567 16 AMT D 50.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 837 Institutional Companion Guide Version 38.0 July 2016. 46 REF T4 Y LX 1 SV2 0300 HC:D0999 50.00 UN 1 DTP 472 D8 20120330 SVD H9999 50.00 HC:D0999 0300 1 DTP 573 D8 20120401 SE 41 0039 GE 1 35 IEA 1 000000032 837 Institutional Companion Guide Version 38.0 July 2016. 47 9.9 Paper Generated Institutional Encounter Business Scenario 9: Patient subscriber, Mary Dough, receives services from Mercy Center. Mercy Center submits the claim to Happy Health Plan on a UB-04. Happy Health Plan is the MAO and converts the paper claim into an electronic submission. File String 9: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000032 1 P: GS HC ENH9999 80881 20120816 1144 35 X 005010X223A2 ST 837 0039 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY CENTER XX 1234999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 128752354 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578799A 50.00 83:A:1 A Y Y DTP 434 RD8 20120330-20120331 CL1 9 9 01 PWK OZ AA HI BK:78099 SBR P 18 XYZ1234567 16 AMT D 50.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST 837 Institutional Companion Guide Version 38.0 July 2016. 48 N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0300 HC:D0999 50.00 UN 1 DTP 472 D8 20120330 SVD H9999 50.00 HC:D0999 0300 1 DTP 573 D8 20120403 SE 42 0039 GE 1 35 IEA 1 000000032 837 Institutional Companion Guide Version 38.0 July 2016. 49 9.10 True Coordination of Benefits Institutional Encounter Business Scenario 10: Patient subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Mercy Hospital diagnosed Mary with congestive heart failure and diabetes. Happy Health Plan is the MAO submitting the encounter to CMS. Mary Dough also has healthcare coverage through Other Health Plan, the secondary payer, who has distributed a payment for Mary. File String 10: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578799A 712.00 11:A:1 A Y Y DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 HI BK:78901 NM1 71 1 JONES AMANDA AL XX 1005554104 SBR P 18 XYZ1234567 16 AMT D 700.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE 837 Institutional Companion Guide Version 38.0 July 2016. 50 N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 SBR T 18 XYZ3489388 16 CAS CO 223 700.00 AMT D 12.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 OTHER HEALTH PLAN XV PAYER01 N3 400 W 21 ST N4 NORFOLK VA 235059999 DTP 573 D8 20120401 REF T4 Y LX 1 SV2 0300 HC:81099 712.00 UN 1 DTP 472 D8 20120330 SVD H9999 700.00 HC:D0999 0300 1 CAS CO 45 12.00 DTP 573 D8 20120401 SE 56 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 51 9.11 Bundled Institutional Encounter Business Scenario 11: Patient subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Happy Health Plan was the MAO. Mercy Hospital diagnosed Mary with Congestive Health Failure as the primary diagnosis and diabetes. File String 11: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 100.00 11:A:1 A Y Y DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 HI BK:4280 HI BJ:4280 HI BF:25000 HI BR:3121:D8:20120330 HI BH:41:D8:20110501 BH:27:D8:20110715 BH:33:D8:20110718 BH:C2:D8:20110729 HI BE:30:::20 HI BG:01 NM1 71 1 JONES AMANDA AL XX 1005554104 837 Institutional Companion Guide Version 38.0 July 2016. 52 SBR P 18 XYZ1234567 16 AMT D 9.48 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 HC:82374 50.00 UN 1 1 DTP 472 D8 20120401 SVD H9999 9.48 HC:80051 1 CAS CO 45 40.52 DTP 573 D8 20120403 LX 2 SV2 HC:82435 50.00 UN 1 11 DTP 472 D8 20120401 SVD H9999 0.00 HC:80051 1 1 CAS OA 97 50.00 DTP 573 D8 20120403 SE 57 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 53 9.12 Skilled Nursing Facility Encounter Business Scenario 12: Patient subscriber, Mary Dough, was admitted into Mercy Health and Rehabilitation SNF for intensive physical therapy services. Happy Health Plan was the MAO. The SNF admitted Mary for inpatient monitoring and physical therapy for a fractured femur. Her length of stay was from 07 10 2014 through 07 26 2014. File String 12: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HEALTH AND REHAB XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 25453.42 21:A:1 A Y Y DTP 096 TM 0958 DTP 434 RD8 20140710-20140726 DTP 435 D8 20140710 CL1 2 9 01 HI BK:82021 HI BJ:82021 HI BH:50:D8:20140726 NM1 71 1 LEACH ELIZA AL XX 1005554104 SBR P 18 XYZ1234567 16 AMT D 25453.42 OI Y Y 837 Institutional Companion Guide Version 38.0 July 2016. 54 NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0022 HP:RML21 0 UN 1 1 LX 2 SV2 0420 HC:97110 25453.42 UN 14 DTP 472 RD8 20140712-20140726 SVD H9999 25453.42 HC:98925 0022 14 DTP 573 D8 20140930 SE 57 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 55 10.0 Encounter Data Institutional Processing and Pricing System Edits After an Institutional encounter passes translator and CEM level editing and receives an ICN on the 277CA acknowledgement report, the EDFES then transfers the encounter to the Encounter Data Institutional Processing and Pricing System (EDIPPS), where editing, processing, pricing, and storage occurs. In order to assist MAOs and other entities with submission of encounter data through the EDIPPS, CMS has provided the current list of the EDIPPS edits identified in Table 14. Note: The edit descriptions listed into Table 14 were revised to identify a maximum of 41 characters in order to display a more comprehensive explanation of edits on the MAO-002 Reports. The EDIPPS edits are organized in nine (9) different categories, as provided in Table 14, Column 2. The EDIPPS edit categories include the following: Validation Provider Beneficiary Reference Limit Conflict Pricing Duplicate NCCI Table 14, Column 3 identifies two (2) edit dispositions: Informational and Reject. Informational edits will cause the encounter to be flagged; however, the Informational edit will not cause processing and or pricing to cease. Reject edits will cause an encounter to stop processing and or pricing, and the MAO or other entity must resubmit the encounter through the EDFES. The encounter must then pass translator and C1 level editing prior to transferring the data to the EDIPPS for reprocessing. The EDIPPS edit description, as found in Table 14, Column 4, is included on the EDPS transaction reports to provide further information for the MAO or other entity to identify the specific reason for the edit generated. If there is no reject edit at the header level and at least one of the lines is accepted, then the encounter is accepted. If there is no reject edit at the header level, but all lines reject, then the encounter will reject. If there is a reject edit at the header level, the encounter will reject. Table 14 reflects only the currently programmed EDIPPS edits. MAOs and other entities should note that, as testing progresses, it may be determined that the current edits require modifications, additional edits may be necessary, or edits may be deactivated. MAOs and other entities must always reference the most recent version of the CMS EDS 837-I Companion Guide to determine the current edits in the EDIPPS. 837 Institutional Companion Guide Version 38.0 July 2016. 56 TABLE 14 ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS EDIPPS EDIT EDIPPS EDIT CATEGORY EDIPPS EDIT DESCRIPTION EDIPPS EDIT ERROR MESSAGE 00010 Validation Reject From DOS Greater Than TCN Date 00011 Validation Reject Missing DOS in Header Line 00012 Validation Reject DOS Prior to 2012 00025 Validation Reject Through DOS After Receipt Date 00030 Validation Reject ICD-10 Dx Not Allowed 00035 Validation Reject ICD-9 Dx Not Allowed 00175 Validation Reject Verteporfin 00195 Validation Informational Wrong Setting for Autologous PRP 00200 Validation Informational Clinical Trial Billing Error 00265 Validation Reject Correct Replace or Void ICN Not in EODS 00699 Validation Reject Void Must Match Original 00750 Pricing Reject Service(s) Not Covered Prior To 4 1 2013 00755 Validation Reject Void Encounter Already Void Adjusted 00760 Validation Reject Adjusted Encounter Already Void Adjusted 00762 Validation Reject Unable to Void Rejected Encounter 00764 Validation Reject Original Must Be Chart Review to Void 00765 Validation Reject Original Must Be Chart Review to Adjust 00775 Validation Reject Unable to Adjust Rejected Encounter 00780 Validation Reject Adjustment Must Match Original 00785 Validation Reject Linked Encounter Not in EODS 00790 Validation Reject Linked Encounter is Voided Adjusted 00795 Validation Reject Linked Encounter is Rejected 00800 Validation Reject Parent ICN Not Allowed for Original 00805 Validation Reject Deleted Diagnosis Code Note Allowed 01405 Provider Reject Sanctioned Provider 01415 Provider Informational Rendering Provider Not Eligible For DOS 02106 Beneficiary Informational Invalid Beneficiary Last Name 02110 Beneficiary Reject Beneficiary HICN Not On File 02112 Beneficiary Reject DOS After Beneficiary DOD 02120 Beneficiary Reject Beneficiary Gender Mismatch 02125 Beneficiary Reject Beneficiary DOB Mismatch 02240 Beneficiary Reject Beneficiary Not Enrolled In MAO For DOS 02256 Beneficiary Reject Beneficiary Not Part C Eligible For DOS 03015 Validation Reject HCPCS Code Invalid for DOS 03022 Pricing Reject Invalid CMG for IRF Encounter 03165 Validation Reject Telehealth Facility Fee Not Allowed 17085 Validation Reject CC 40 Required for Same Day Transfer 17100 Validation Reject DOS Required for HH Encounter 17257 Validation Informational Rev Code 091X Not Allowed 17310 Validation Reject Rev Code 036X Requires Surg Proc Code 837 Institutional Companion Guide Version 38.0 July 2016. 57 TABLE 14 ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS EDIPPS EDIT EDIPPS EDIT CATEGORY EDIPPS EDIT DESCRIPTION EDIPPS EDIT ERROR MESSAGE 17330 Reference Reject RAP Not Allowed 17404 Validation Reject Duplicate CPT HCPCS and Unit Exceeds 1 17407 Validation Reject Modifier Requires HCPCS Code 17735 Validation Reject Modifier Not Within Effective Date 18010 Reference Informational Age and Dx Code Conflict 18012 Reference Informational Gender and Dx Code Conflict 18018 Reference Informational Gender and CPT HCPCS Conflict 18130 Reference Reject Duplicate Principal Dx Code 18135 Reference Reject Principal Dx Code is Manifestation Code 18140 Reference Reject Principal Dx Code is E-Code 18145 Reference Reject Unacceptable Dx Code 18260 Reference Reject HCPCS Required with Submitted Rev Code 18270 Validation Informational Rev Code and HCPCS Required 18300 Validation Reject FQHC Payment Code is Invalid Missing 18305 Validation Reject Invalid Missing FQHC Qualifying Visit 18310 Validation Reject Required FQHC Revenue Code is Missing 18315 Validation Reject Item Service Not Covered Under FQHC 18500 Conflict Informational Multiple CPT HCPCS for Same Service 18540 Reference Informational CPT HCPCS Service Unit Out Of Range 18705 Validation Reject Invalid Discharge Status 18710 Validation Reject Missing Invalid POA Indicator 18730 Reference Informational Invalid Modifier Format 18905 Validation Reject Age Is 0 Or Exceeds 124 20270 Validation Reject From Thru Dates Equal - Day Count 1 20450 Validation Reject Attending Physician is Sanctioned 20455 Validation Informational Operating Provider Is Sanctioned 20495 Validation Reject Revenue Code is Non-Billable for TOB 20500 Conflict Reject Invalid DOS for Rev Code Billed 20505 Conflict Reject Correct Ambulance HCPCS Rev Code Required 20510 Conflict Reject Rev Code 054X Requires Specific HCPCS 20515 Conflict Informational Immunization Dx Must Align with HCPCS 20520 Validation Informational Invalid Ambulance Pick-up Location 20525 Validation Reject Multiple Ambulance Pick-up Locations 20530 Validation Informational Missing Ambulance Pick-up Zip Code 20835 Pricing Reject Service Line DOS Not Within Header DOS 20980 Pricing Informational Provider Cannot Bill TOB 12X or 22X 21925 Pricing Reject Swing Bed SNF Conditions Not Met 21950 Pricing Reject Line Level DOS Required 21951 Pricing Informational No OSC 70 or Covered Days Less Than 3 21958 Pricing Informational Rehab Therapy Ancillary Codes Required 837 Institutional Companion Guide Version 38.0 July 2016. 58 TABLE 14 ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS EDIPPS EDIT EDIPPS EDIT CATEGORY EDIPPS EDIT DESCRIPTION EDIPPS EDIT ERROR MESSAGE 21976 Validation Informational OSC 70 Dates Outside of Coverage Period 21979 Validation Reject Charges for Rev Code 0022 Must Be Zero 21980 Validation Reject CC D2 Requires Change in One HIPPS 21994 Validation Informational From Date Greater Than Admit Date 22015 Validation Informational Number of Days Conflicts With HH Episode 22020 Validation Informational Conflict Between CC and OSC 22095 Validation Reject Encounter Must Be Submitted on 837-P DME 22100 Validation Informational Rev Code 0023 Invalid for DOS 22135 Validation Reject Multiple Rev Code 0023 Lines Present 22205 Validation Reject Service Line Missing DOS 22220 Validation Reject Admit Provider Effective Date Conflict 22225 Validation Informational Missing Provider Specific Record 22280 Validation Reject Rev Code 277 Invalid for a HH 22290 Validation Reject Service Line Requires DOS 22320 Validation Informational Missing ASC Procedure Code 22340 Validation Reject ESRD Diagnosis Code Missing 22355 Validation Reject Inpatient Service Line Error 22375 Validation Reject Item Service Not Covered for RHC 22390 Validation Reject HIPPS Code Required for SNF HH (DOS on or after 7 1 2014) 22395 Validation Reject HIPPS Codes Conflicts with Revenue Code (DOS on or after 7 1 2014) 22400 Validation Reject HP Qualifier Must Exist for HIPPS Code (DOS on or after 7 1 2014) 22405 Validation Reject Occurrence Code 55 DOD Required (DOS on or after 01 01 2013) 22410 Pricing Reject Invalid Service(s) for TOB 22415 Pricing Reject Revenue Code 0274 Required 22420 Validation Reject TOB 33X Invalid for DOS 22430 Validation Reject HCPCS Codes with Invalid TOB 25000 NCCI Informational CCI Error 27000 Validation Reject Height or Weight Value Exceeds Limit 98300 Duplicate Reject Exact Inpatient Duplicate Encounter 98315 Duplicate Reject Linked Chart Review Duplicate 98320 Duplicate Reject Chart Review Duplicate 98325 Duplicate Reject Service Line(s) Duplicated 837 Institutional Companion Guide Version 38.0 July 2016. 59 10.1 EDIPPS Edits Enhancements Implementation Dates As the EDS matures, the EDPS may require enhancements to the EDIPPS editing logic. As enhancements occur, CMS will provide the updated information (i.e., disposition changes and activation or deactivation of an edit). Table 15 provides MAOs and other entities with the implementation dates for enhancements made to the EDIPPS since the last release of the CMS EDS 837-I Companion Guide. TABLE 15 EDIPPS EDITS ENHANCEMENTS IMPLEMENTATION DATES EDIT EDIT DISPOSITION EDIT DESCRIPTION ENHANCEMENT ENHANCEMENT DATE 00800 Reject Parent ICN Not Allowed for Original New Edit Implemented 7 8 16 00805 Reject Deleted Diagnosis Code Not Allowed New Edit Implemented 7 8 16 18730 Informational Invalid Modifier Format Changed to Informational Disposition 7 8 16 22375 Reject Item Service Not Covered For RHC New Edit Implemented 7 8 16 Note: Table 15 will not be provided when there are no enhancements implemented for the current release of the CMS EDS Companion Guides. 10.2 EDIPPS Edits Prevention and Resolution Strategies In order to assist MAOs and other entities with the prevention of potential errors in their encounter data submission and with resolution of edits received on the generated MAO-002 reports, CMS has provided comprehensive strategies and scenarios. CMS has identified strategies and scenarios in three (3) phases. 10.2.1 EDIPPS Edits Prevention and Resolution Strategies Phase I: Frequently Generated EDIPPS Edits Table 16 outlines Phase 1 of the prevention and resolution strategies for Institutional edits most frequently generated on the MAO-002 reports. TABLE 16 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE I Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17310 Rev Code 036X Requires Surg Proc Code Reject Revenue Code 036X must be submitted with a required surgical ICD-9 CM procedure code for TOBs 11X, 18X, or 21X. Scenario: Life and Health Associates submitted an encounter for Galaxy Suburb Hospital for a prostate cryosurgery performed on 5 15 2012. The encounter was populated with Revenue Code of 036X, but did not include ICD-9-CM procedure code 6062. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17407 Modifier Requires HCPCS Code Reject Service line submitted with HCPCS modifier, but not the required HCPCS code. Verify that codes modifiers are accurate. 837 Institutional Companion Guide Version 38.0 July 2016. 60 Scenario: Dr. Whitty submitted the HCPCS modifier code 25- Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure, without the appropriate level of E M service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17735 Modifier Not Within Effective Date Reject Modifier not active for DOS reported. Submitter must verify that modifiers reported are valid and current. Scenario: As a follow up to a postoperative surgery on 8 1 2012, Dr. Whitty submitted HCPCS modifier code 21- Prolonged evaluation and management services on 9 28 2012; however, the modifier was deactivated on 9 1 2012. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20270 From Thru Dates Equal - Day Count 1 Reject Inpatient encounter contains same from and through DOS; however, the day count reported in Loop 2320 MIA15 does not equal 1. Verify that DOS are accurate or that day count is equal to 1. Scenario: Nightline Hospital admitted a patient at 8 p.m. on 10 23 2012 and the patient was discharged at 2 p.m. on 10 24 2012. Dawn to Dusk Healthcare submitted the encounter with a day count of 2 for admission, although the overnight stay is considered one (1) day. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20505 Correct Ambulance HCPCS Rev Code Required Reject Revenue Code 540 populated without appropriate ambulance HCPCS codes and or a unit greater than 1 for the HCPCS code. Also provide HCPCS mileage codes. Scenario: Blue Flight Health Plan submitted an encounter for ground ambulance services with Revenue Code 540; however, the HCPCS code was not populated. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20510 Rev Code 054X Requires Specific HCPCS Reject HCPCS code is not valid for submission with Revenue Code 540. Use an appropriate HCPCS code from the list of HCPCS codes acceptable for submission with Revenue Code 540. Scenario: Blue Flight Health Plan submitted a ground transportation ambulance Revenue Code 540 with a HCPCS code A0021-Out of State Per Mile, which was valid for the service, but is invalid for Medicare. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20530 Missing Ambulance Pick-up Zip Code Informational Submitter should provide a valid nine (9)-digit ZIP code for ambulance pick-up location on ambulance encounters submitted on an Institutional encounter. (See formatting guidance in Section 5.1, Table 4.) Scenario: Mystery Health Plan submitted an encounter on behalf of Rush Ambulance with an ambulance ZIP code populated as 0 in Loop segment 2300 HI01-05. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20835 Service Line DOS Not Within Header DOS Reject Line level DOS reported that does not fall within from and through DOS range reported on header level of encounter. Verify the accuracy of all DOS. Scenario: Who Knows Hospital admitted Janet Doe on 6 1 2012 and discharged her on 6 10 2012. Padre Care Plan submitted an inpatient encounter on behalf of Who Knows Hospital for Ms. Doe. The service line DOS were correct; however, the claim header indicated that Ms. Doe was admitted on 6 6 2012 and discharged on 6 12 2012. 837 Institutional Companion Guide Version 38.0 July 2016. 61 10.2.2 EDIPPS Edits Prevention and Resolution Strategies Phase II: Common EDPS Edits Table 17 outlines Phase II for common edits generated in all subsystems of the EDPS (Professional, Institutional, and DME). TABLE 17 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE II Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00010 From DOS Greater Than TCN Date Reject Encounter must have a DOS prior to submission date. Scenario: Perfect Health of America submitted an encounter to the EDS on 5 10 2012 for a knee replacement performed at Wonderful Hills Mediplex for DOS of 6 20 2012. The encounter was rejected because the from DOS was after the date of encounter submission. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00011 Missing DOS in Header Line Reject Encounter header and line levels must include from and through DOS | /kaggle/input/edi-db-835-837/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_1 |
equal to 1. Scenario: Nightline Hospital admitted a patient at 8 p.m. on 10 23 2012 and the patient was discharged at 2 p.m. on 10 24 2012. Dawn to Dusk Healthcare submitted the encounter with a day count of 2 for admission, although the overnight stay is considered one (1) day. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20505 Correct Ambulance HCPCS Rev Code Required Reject Revenue Code 540 populated without appropriate ambulance HCPCS codes and or a unit greater than 1 for the HCPCS code. Also provide HCPCS mileage codes. Scenario: Blue Flight Health Plan submitted an encounter for ground ambulance services with Revenue Code 540; however, the HCPCS code was not populated. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20510 Rev Code 054X Requires Specific HCPCS Reject HCPCS code is not valid for submission with Revenue Code 540. Use an appropriate HCPCS code from the list of HCPCS codes acceptable for submission with Revenue Code 540. Scenario: Blue Flight Health Plan submitted a ground transportation ambulance Revenue Code 540 with a HCPCS code A0021-Out of State Per Mile, which was valid for the service, but is invalid for Medicare. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20530 Missing Ambulance Pick-up Zip Code Informational Submitter should provide a valid nine (9)-digit ZIP code for ambulance pick-up location on ambulance encounters submitted on an Institutional encounter. (See formatting guidance in Section 5.1, Table 4.) Scenario: Mystery Health Plan submitted an encounter on behalf of Rush Ambulance with an ambulance ZIP code populated as 0 in Loop segment 2300 HI01-05. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20835 Service Line DOS Not Within Header DOS Reject Line level DOS reported that does not fall within from and through DOS range reported on header level of encounter. Verify the accuracy of all DOS. Scenario: Who Knows Hospital admitted Janet Doe on 6 1 2012 and discharged her on 6 10 2012. Padre Care Plan submitted an inpatient encounter on behalf of Who Knows Hospital for Ms. Doe. The service line DOS were correct; however, the claim header indicated that Ms. Doe was admitted on 6 6 2012 and discharged on 6 12 2012. 837 Institutional Companion Guide Version 38.0 July 2016. 61 10.2.2 EDIPPS Edits Prevention and Resolution Strategies Phase II: Common EDPS Edits Table 17 outlines Phase II for common edits generated in all subsystems of the EDPS (Professional, Institutional, and DME). TABLE 17 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE II Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00010 From DOS Greater Than TCN Date Reject Encounter must have a DOS prior to submission date. Scenario: Perfect Health of America submitted an encounter to the EDS on 5 10 2012 for a knee replacement performed at Wonderful Hills Mediplex for DOS of 6 20 2012. The encounter was rejected because the from DOS was after the date of encounter submission. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00011 Missing DOS in Header Line Reject Encounter header and line levels must include from and through DOS (procedure or service start date). Scenario: Chloe Pooh was admitted to Regional Port Hospital on 10 21 2012 for a turbinectomy and was released on 10 22 2012. Regional Port Hospital submitted a claim to Robbins Health for the surgical procedure. Robbins Health submitted the encounter to the EDS, but did not include the through DOS of 10 22 2012. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00012 DOS Prior to 2012 Reject Encounter must contain 2012 through DOS for each line. Scenario: Ion Health submitted an encounter with DOS from 12 2 2011 through 12 28 2011, for an inpatient admission at Better Health Hospital. EDS will only process encounters that include 2012 through DOS or later. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00025 Through DOS After Receipt Date Reject Encounter submitted with a service line through DOS that occurred after the date the encounter was submitted. Scenario: Leverage Community Health submitted an encounter on 8 23 2012 for a myringotomy performed by Dr. Earwell. The service line DOS for the procedure was on 8 29 2012. The encounter was rejected because the encounter was submitted to the EDS prior to the DOS listed on the encounter. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00265 Correct Replace or Void ICN Not in EODS Reject Replacement or void encounter submitted with an invalid ICN. Verify accuracy of ICN on the returned MAO-002 report. Scenario: Chance Medical Services submitted an encounter to the EDS and received an MAO-002 report with an accepted ICN of 123456789. The encounter required an adjustment (void or replacement). Chance Medical Services submitted a replacement encounter using ICN 234567899. The replacement encounter was rejected because there was no original record in the EDS for this ICN with the same Submitter ID. 837 Institutional Companion Guide Version 38.0 July 2016. 62 TABLE 17 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE II (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00699 Void Must Match Original Reject When submitting a void, MAOs must match the linked ICN, HICN, Last Name, First Name, TOB, Submitted Charges, DOS, Payer ID, and the service lines of an accepted encounter stored in the EODS. Note: The EDPS will validate the beneficiary s demographic data (HICN, Last Name, First Name) according to the Medicare Beneficiary Database (MBD), as well as validate the beneficiary s Billing Provider NPI and Rendering Provider NPI (if applicable) prior to posting edit 00699. Scenario: Grantham Healthcare submitted an encounter for pre-operation lab work for Juno Brac containing five (5) service lines. Torchlight Healthcare then submitted a void encounter for the same annual physical; however, the void encounter contained only four (4) of the five (5) original service lines. Torchlight Healthcare received an MAO-002 report with edit 00699 for the void encounter because one (1) of the service lines from the original encounter was not included on the void encounter. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 01405 Sanctioned Provider Reject Submitter must ensure that provider (billing and or rendering) was not suspended or terminated from providing services for Medicare beneficiaries during the time(s) of service indicated on the encounter. Scenario: Dr. Domuch performed a cystectomy for Wally Dowright on 10 2 2012. Dr. Domuch submitted a claim to Dermis Health Plan, who adjudicated the claim and submitted an encounter to the EDS. The EDS returned the encounter to Dermis Health Plan with edit 01405 because Dr. Domuch s privileges were suspended, effective 8 29 2012, for one (1) year; therefore, Dr. Domuch was not authorized to perform this procedure. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 01415 Rendering Provider Not Eligible For DOS Informational Verify that NPI is accurate and that the provider was eligible for DOS submitted. Scenario: ABC Care Plan submitted an encounter for a procedure performed by Dr. Destiny on 2 14 2012. The EDPS provider reference files indicate that Dr. Destiny s NPI was not effective until 2 16 2012. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02106 Invalid Beneficiary Last Name Informational Verify that last name populated on the encounter matches the last name listed in CMS systems. Scenario: Blue Skies Rural Health submitted an encounter for patient Ina Batiste-Rhogin. The CMS system listed the patient as Ina Rhogin. The EDPS processed and accepted the encounter with an informational flag indicating that the name provided on the encounter was not identical to the name listed in the CMS systems. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02110 Beneficiary HICN Not On File Reject Verify that HICN populated on the encounter is valid in CMS systems. Scenario: Bright Medical Center submitted a claim to Sunshine Complete Health for an office visit for Mr. Everett Banks for DOS of 5 26 2012. Sunshine Complete Health submitted an encounter to the EDS. The EDS rejected the encounter with edit 02110, because the HICN populated on the encounter was not on file in the CMS systems. 837 Institutional Companion Guide Version 38.0 July 2016. 63 TABLE 17 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE II (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02112 DOS After Beneficiary DOD Reject Verify that DOS submitted is accurate and does not exceed the beneficiary DOD. Scenario: Mountain Hill Health submitted an encounter for an inpatient admission for Ray Rayson for DOS of 7 15 2012. EDPS was unable to process the encounter because the CMS systems indicated Mr. Rayson expired on 7 13 2012. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02120 Beneficiary Gender Mismatch Reject Verify that gender populated on the encounter is accurate and matches gender listed in CMS systems. Scenario: Jenna Jorgineski went to Lollipop Lab for a sleep study on 9 4 2012. Lollipop Lab submitted a claim for the sleep study to Capital City Community Care with Ms. Jorgineski s gender identified as male. Capital City Community Care submitted the encounter. The EDS processed and accepted the encounter. The MAO-002 report was returned with edit 02120, because Ms. Jorgineski s gender was listed as female in the CMS systems. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02125 Beneficiary DOB Mismatch Reject Verify that DOB populated on the encounter matches DOB listed in CMS systems. The EDPS will accept these encounters within plus or minus two (2) years of beneficiary s birth year. Note: CMS anticipates that the change in this edit will be short-term and expects plan sponsors to improve their submission of DOBs. Scenario: Watchman Health submitted an encounter to the EDS for Texas Joe, listing Mr. Joe s DOB as 9 8 1965. The CMS systems listed Mr. Joe s DOB as 9 8 1956. The EDS returned the MAO-002 report to Watchman Health with edit 02125 due to the conflicting dates of birth beyond the two (2)-year variance. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02240 Beneficiary Not Enrolled In MAO For DOS Reject Verify that beneficiary was enrolled in your contract during DOS on the encounter. If the beneficiary is not enrolled in your contract for the DOS on the encounter, do not submit the encounter. Encounters should only be submitted for DOS in which the beneficiary is enrolled in your contract. Scenario: Gabrielle Boyd was admitted to Faith Hospital for an appendectomy on 6 11 2012 and was discharged on 6 14 2012. Faith Hospital submitted the claim for the hospital admission to Adams Healthcare. Adams Healthcare adjudicated the claim and submitted an encounter to the EDS on 7 12 2012. Ms. Boyd s effective date with Adams Healthcare was 7 1 2011. The EDS returned an MAO-002 report to Adams Health with edit 02240 because Ms. Boyd was not enrolled with the health plan for the DOS submitted by Faith Hospital. 837 Institutional Companion Guide Version 38.0 July 2016. 64 TABLE 17 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE II (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02256 Beneficiary Not Part C Eligible For DOS Reject Verify that beneficiary was enrolled in Part C for DOS listed on the encounter. Encounters should not be submitted for beneficiaries not enrolled with the contract for the DOS on the received claim. Encounters should only be submitted for DOS for which the beneficiary is actually enrolled with your contract. Scenario: On 7 4 2012, Gail Williams has severe chest pains and goes to the emergency room for a chest x-ray at Underwood Memorial Hospital. At the time of the emergency room visit, Ms. Williams only has Part A Medicare coverage, and her Part C Medicare coverage is effective 8 1 2012. Underwood Memorial submits the claim to AmeriHealth. AmeriHealth submits an encounter to the EDS, which is rejected with edit 02256, because Ms. Williams is not covered under Part C Medicare for the DOS. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 25000 CCI Error Informational Ensure CCI code pairs are appropriately used. Ensure that CCI single codes meet the MUE allowable units of service (UOS). Scenario: Hippos Health Plan submitted an encounter to the EDS with a DOS of 5 5 2012 and HCPCS code 15780 and two (2) units of service. The returned MAO-002 report indicated an informational edit of 25000 because HCPCS code 15780 dermabrasion, is only valid for one (1) unit of service per day. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 98325 Service Line(s) Duplicated Reject Verify encounter was not previously submitted and or the service line does not contain the exact same data elements as a previously submitted service line on the same encounter (Refer to the Section 8.0 Duplicate Logic in this companion guide for duplicate logic validation elements.) Note: The EDPS will bypass edit logic for 98325 when modifier 59, 62, 66, 76, 77, and or 91 is submitted on one (1) of multiple service lines containing the exact same data elements. Scenario: Sanford Health Systems submitted an encounter on 6 15 2015 for a claim received from Sky High Hospital containing two (2) service lines for 15-minute therapy services. The encounter lines submitted were the same for the timed procedure code, totaling 35 minutes and should have been submitted with two (2) units of service under the total time rather than as separate duplicate lines. 837 Institutional Companion Guide Version 38.0 July 2016. 65 10.2.3 EDIPPS Edits Prevention and Resolution Strategies Phase III: General EDIPPS Edits Table 18 outlines Phase III for a portion of the remaining Institutional edits generated on the MAO-002 Encounter Data Processing Status Reports. Section 10.2.3 will be updated in future releases of the Institutional Companion Guide until all remaining edits are identified. TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00195 Wrong Setting for Autologous PRP Informational Encounters containing HCPCS code G0460 must only be billed with TOB 12X, 13X, 22X, 23X, 71X, 75X, 77X, or 85X. Scenario: New Balance Home Health submitted an encounter for the purpose of billing Autologous Platelet-Rich Plasma (PRP) for a Mr. Garret s non-healing wound. The service was submitted using HCPCS Code G0460 and TOB 34X. The EDS posted error code 00195 because Home Health providers cannot administer this service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00200 Clinical Trial Billing Error Informational Clinical trial encounters must contain Modifier Q0, Condition Code 30, and clinical trial-specific ICD-9 10 Diagnosis Code V70.7 Z00.6. Scenario: Coagulate Community Health submitted a clinical trial encounter for patient Mr. Bumbly. The service was submitted with modifier Q0 and ICD-9 diagnosis code V70.7, but did not contain Condition Code 30, as required for clinical trial submissions to the EDS. The EDS posted error code 00200 because the clinical trial encounter must contain Condition Code 30. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18010 Age and Dx Code Conflict Informational Verify that diagnosis populated on the encounter is age appropriate for beneficiary Scenario: Clear Path Health submitted an encounter to the EDS for services provide to Mr. Jackson Leigh, who is 85-yrs old. The diagnosis provided on the encounter was V20.2-routine child health check. The MAO-002 report returned contained an informational edit of 18010 because the diagnosis provided was not appropriate for an 85-yr old. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18018 Gender and CPT HCPCS Conflict Informational Gender provided for beneficiary does not agree with procedure service identified on the encounter. Verify gender populated on encounter matches date in the CMS systems. Ensure that the procedure code is accurate and appropriate. Scenario: Claims Health submitted an encounter for Jane Johnson with procedure code 58150-Total Hysterectomy. However, the gender populated on the encounter identified Ms. Johnson as a male. The MAO-002 report was returned with an informational error of 18018. CMS recommends that Claims Health verify the gender on Ms. Johnson s HICN information to ensure that it is corrected. 837 Institutional Companion Guide Version 38.0 July 2016. 66 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18135 Principal Dx is Manifestation Code Reject Encounter submitted using a code for underlying disease or symptom instead of a principal diagnosis. Ensure that primary diagnosis is valid. Scenario: Arbor Meadows Health submitted an encounter for an inpatient admission for Ms. Anabel Greaves. The diagnosis submitted on the encounter was 3214-Meningitis due to sarcoidosis. The EDS rejected the encounter because 3214 is not a primary diagnosis, but is a manifestation code for a condition related to the diagnosis. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18260 Invalid Rev Code Reject Encounter submitted with a Revenue Code not related to services provided or a Revenue Code not used. Scenario: Home Sweet Home submitted a claim to Foundation Health for Home Health services provided to Ms. Jean. Foundation Health submitted the encounter to the EDS using Revenue Code 0022. The encounter was rejected for edit 18260 because Foundation Health used a SNF revenue code for a Home Health encounter. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18270 Rev Code and HCPCS Required Informational Certain revenue codes require HCPCS codes on the same service lines. TOBs 12X, 13X, 14X, 74X, 75X, and 76X billed without condition code 41 and include a relevant revenue code that requires a HCPCS code will receive this edit. Scenario: Julie Barber was seen by Dr. Jo at Saint Mary Hospital for a hearing evaluation. Dr. Jo submitted a TOB 141 encounter with HCPCS code 92506 (Speech Hearing Evaluation) but did not include revenue code 0440. The MAO submitted the encounter to the EDS which posted edit 18270 to advise the MAO that revenue codes are required with the submitted HCPCS code. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18300 FQHC Payment Code is Invalid Missing Reject An FQHC encounter (TOB 77X) must include a valid payment HCPCS code (G0466, G0467, G0468, G0469, or G0470) on the encounter service line for each billed service date. Scenario: Heelum Health Center submitted an FQHC encounter using bill type 77X and only submitted HCPCS code G0463. The EDPS rejected the encounter because the encounter did not contain an FQHC payment HCPCS code. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18305 Invalid Missing FQHC Qualifying Visit Reject FQHC encounters (TOB 77X) must include a qualifying visit procedure code related to the FQHC payment codes G0466, G0467, G0468, G0469, or G0470 for the same date of service. Scenario: Howard Cankle was treated by Heelum Health Center on 11 20 2014 for an annual wellness visit (G0468). Heelum Health Center submitted an encounter (bill type 77X) for Howard Cankle with visit code 92002 (eye exam, new patient). The EDPS rejected the service line because 92002 is not a valid visit code for payment code G0468. 837 Institutional Companion Guide Version 38.0 July 2016. 67 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18310 Required FQHC Revenue Code is Missing Reject FQHC encounters (TOB 77X) must include a valid revenue code on the same service line for the payment HCPCS codes G0466, G0467, G0468, G0469, or G0470. Scenario: Heelum Health Center submitted an encounter (TOB 77X) for Eileen Bentley s annual eye exam (FQHC payment code G0467, visit code 92012) and revenue code 0530. The EDPS rejected the service line because revenue code 0530 is used for Osteopathic Services. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18315 Item Service Not Covered Under FQHC Reject All FQHC encounter service lines must contain only qualified FQHC services. Scenario: Heelum Health Center submitted an encounter (TOB 77X) including a service line for Dr. Smart s professional fees. The EDPS rejected the service line because Dr. Smart s professional fees are not acceptable FQHC services even though Dr. Smart is an FQHC provider. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18540 CPT HCPCS Service Unit Out Of Range Informational Procedures submitted with number of units not permitted by the procedure will receive this edit. Scenario: Cinderella Hospital submitted an encounter with HCPCS code 51860 for the bladder wound repair of Rob Snyder and billed two (2) units for the service. The encounter was rejected because submitters can only bill one (1) unit with HCPCS code 51860. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18705 Invalid Discharge Status Reject Providers must use the correct patient status code in loop 2300 and segment CL103 in conjunction with the submitted type of bill and beneficiary status. Scenario: Crisis Clinton Hospital submitted a TOB 112 encounter for Gary Fargo and the patient status code 01 was populated. The EDS posted edit 18705 as the encounter should have included patient status code 30 (still a patient) since TOB 112 was used for a continuous stay patient. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21950 Line Level DOS Required Reject Certain procedures services require date(s) of service at the service line. The EDPS will post error code 21950 when an Institutional encounter submitted with HCPCS codes other than Q0163 through Q0181 does not contain service line date(s) of service. Scenario: Norview East Hospital submitted an encounter for Claire Beauchamp for an inpatient stay where continuous glucose monitoring was performed. The encounter service line contained HCPCS code 95250 but no service line dates of service. The EDS rejected the encounter due to missing DOS at the service line. 837 Institutional Companion Guide Version 38.0 July 2016. 68 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21958 Rehab Therapy Ancillary Codes Required Informational The EDS will notify MAOs when Rehabilitation Therapy encounters submitted through TOB 18X or 21X and revenue code 0022 do not contain the proper combination of HIPPS codes and related Rehabilitation Therapy Ancillary Revenue Codes. Scenario: Sleeping Beauty Skilled Nursing Facility (SNF) submitted a TOB 21X encounter containing HIPPS Code RUAxx, but none of the following rehabilitation ancillary codes: 42X, 43X, or 44X. The EDS posted error code 21958 since this encounter contained an inaccurate combination of HIPPS codes and related Rehabilitation Therapy Ancillary Revenue Codes. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21980 CC D2 Requires Change in One HIPPS Reject Replacement encounter submitted with condition code D2; however, the associated HIPPS code was not revised to indicate the replacement. Scenario: Marxton Health sent a replacement encounter to the EDS on behalf of Here For You Health, which contained condition code of D2 and an appropriate reason code to revise the HIPPs code originally submitted, but the HIPPS code itself was not revised. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00755 Void Encounter Already Void Adjusted Reject Submitter has previously voided an encounter and is attempting to void the same encounter. Submitter should review returned MAO-002 reports to confirm processing of the voided encounter prior to resubmission of the void. Scenario: Happy Trails Health Plan submitted a void encounter on 10 10 2012. Happy Trails Health Plan voided the same encounter, in error, on 10 15 2012, prior to receiving the MAO-002 report for the initial void encounter, which was returned on 10 16 2012. The MAO-002 report for the subsequent voided encounter was returned with edit 00755 due to the submission of the second void encounter. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00760 Adjusted Encounter Already Void Adjusted Reject Submitter has previously voided an encounter and is attempting to replace the same voided encounter. Submitter should review returned MAO-002 reports to confirm processing of the voided encounter prior to resubmission replacement. Scenario: On 8 20 2012, Pragmatic Health submitted a replacement encounter for ICN 123456789 to correct a CPT code. However, Pragmatic Health had already submitted a void for the same ICN on 8 18 2012, but had not yet received the MAO-002 report by 8 20 2012. Pragmatic Health received edit 00760 on a subsequent MAO-002 report because the EDPS had already processed the void encounter submitted on 8 18 2012. 837 Institutional Companion Guide Version 38.0 July 2016. 69 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00762 Unable to Void Rejected Encounter Reject Submitter is attempting to void a previously rejected encounter. Submitter should review returned MAO-002 reports to confirm the rejected encounter. Scenario: On 7 20 2012, Hero Health Plan submitted an encounter with an invalid HICN. On 7 26 2012, Hero Health Plan attempted to void the encounter due to the invalid HICN without referencing the MAO-002 report, dated 7 25 2012, that indicated that the encounter was rejected. On 8 1 2012, Hero Health Plan received an MAO-002 report with edit 00762 for the voided encounter because the original encounter had already been processed and rejected. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17330 RAP Not Allowed Reject Encounter submissions are not allowed for Type of Bill 322 or 332 (Request for Anticipated Payment) Scenario: Magic Morning Health Plan submitted an encounter to the EDS for BackHome Health (a primary HHA) with TOB 322. The encounter was rejected because the EDS does not accept Request for Anticipated Payment (RAP) encounters. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18012 Gender and Dx Code Conflict Informational Encounter submitted with a beneficiary gender that does not agree with the diagnosis populated on the encounter. Scenario: Hindsight Health submitted an encounter for JuneBug Hospital for Mr. James Jewet with diagnosis code 641.1 Hemorrhage from placenta previa. The encounter was rejected because the diagnosis submitted is a female specific diagnosis. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18130 Duplicate Principal Dx Code Reject Secondary diagnosis code submitted is a duplicate of the primary diagnosis code. Scenario: Solo Health Services submitted an encounter with a diagnosis code 413.9 in the BK (primary diagnosis) and BF (additional diagnosis) qualifier fields for the same service line. The encounter was rejected for duplicate primary diagnoses. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18145 Unacceptable Dx Code Reject The diagnosis code populated on the encounter is invalid or incorrectly populated. Scenario: Hopewell Health Plan submitted an encounter to the EDS for Cornerstone Hospital for services provide to Colonel Marcus on 2 3 2012. The diagnosis populated on the encounter was 518.5 Pulmonary Insufficiency Following Trauma or Surgery. The encounter was rejected for an unacceptable diagnosis because diagnosis code was deleted and deemed invalid effective 10 1 2011. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21994 From Date Greater Than Admit Date Informational Encounter submitted with a 'from' date prior to the date of the beneficiary s admission. Scenario: Allison Oop was admitted to Mad Hatter Nursing Facility at 2:46 AM on 4 1 2012. Holiday Health submitted the SNF encounter to the EDS with an admit date of 4 1 2012, but the service line from date was listed as 3 29 2012. 837 Institutional Companion Guide Version 38.0 July 2016. 70 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22220 Admit Provider Effective Date Conflict Reject Admission date indicated on encounter occurred before the provider s NPI was deemed active effective. Note: The EDPS will validate bill types prior to posting edit 22220. Scenario: Halo Home Health submitted an encounter to the EDS for Mr. Sweets admission on 1 28 2011 for DOS from 2 1 2012 through 2 11 2012 with NPI 0002220001. The encounter was rejected because the NPI effective date was 2 2 2012, after the admission date. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00764 Original Must Be a Chart Review to Void Reject Submitter must ensure that, if the void encounter (frequency code 8 ) is populated with PWK01 09 and PWK02 AA, the original encounter submission was a chart review encounter populated with PWK01 09 and PWK02 AA. The submitter must also ensure that the ICN references the initial chart review encounter, not the original full encounter. Scenario: On 1 12 2013, Paisley Community Health submitted an original encounter for Mr. Jolly Jones to the EDS and received the accepted ICN of 3029683010582. On 2 2 2013, Paisley Community Health submitted a chart review encounter to the EDPS to delete a diagnosis code from the original encounter and received the accepted ICN of 5039530285074. In April 2013, Paisley Community Health performed another chart review of Mr. Jones medical records and discovered that the service was never provided. Paisley Community Health submitted a void encounter to the EDS using the reference ICN of 3029683010582 (the original encounter ICN) and populated PWK01 09 and PWK02 AA. The EDS rejected the encounter because the ICN referenced was for the original encounter, not the initial chart review. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00765 Original Must Be a Chart Review to Adjust Reject Ensure that, if the replacement encounter (frequency code 7 ) is populated with PWK01 09 and PWK02 AA, the original encounter submission was a chart review encounter populated with PWK01 09 and PWK02 AA. The submitter must also ensure that the ICN references the initial chart review encounter, not the original encounter. The replacement chart review (frequency code 7 ) must contain all data elements, including all relevant diagnosis codes populated on the original linked chart review encounter (frequency code 1 ). Important Note: The accepted replacement chart review submission will supersede any previous chart review encounter to which it is linked. Scenario: Flashback Health performed a chart review for Prosperous Living Medical Center. Flashback Health discovered two (2) additional diagnosis codes for an encounter previously submitted for Ms. Leanne Liberty. Flashback Health submitted an initial chart review encounter using the frequency code of 7. The EDS rejected the chart review encounter submission because initial chart review encounters should contain a frequency code 1. 837 Institutional Companion Guide Version 38.0 July 2016. 71 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17404 Duplicate CPT HCPCS and Unit Exceeds 1 Reject Encounter should not be submitted with a unit of greater than 1 when any of the following HCPCS codes are provided for a pap smear on a single DOS: Q0060, Q0061, P3000, P3001, Q0091, G0123, G0124, G0143, G0144, G0145, G0147, and G0148 nor can duplicate pap smear HCPCS Codes be submitted for the same day. Scenario: Dr. Michaels performed a pap smear on Miss Annabelle Lee prior to a gynecological procedure. The lab lost the test sample. Dr. Michaels repeated the Pap smear and performed the gynecological procedure. Group Health Plan submitted the encounter for both of Miss Lee s pap smears, using HCPCS code Q0060, and her surgical procedure. The encounter was rejected because Medicare will not allow more than one (1) unit for Q0060 for a single service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18140 Principal Dx Code is E-Code Reject Submitter must ensure that an e-code is submitted as a subsequent diagnosis code. An E-code is never allowed as a primary principal diagnosis code and must not be populated using the BK qualifier Scenario: Marney Gentos was admitted to Home Hospital for second degree burns. Fantasy Life Health Plan submitted the encounter to the EDS and received an accepted ICN. Fantasy Life Health Plan later performed a chart review and located an additional diagnosis code for services provided during Ms. Gentos stay at Home Hospital. Fantasy Life submitted a chart review encounter to the EDS with a single diagnosis code of E9581 Injury-burn, fire. The EDS rejected the chart review submission because e-codes must never be submitted without a primary principal diagnosis. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18905 Age Is 0 Or Exceeds 124 Reject The age of the patient identified on the encounter must not contain non-numeric values; or the age must not be populated as 0 or greater than 124 years old Scenario: Munali Mohair, a 27-yr old female was admitted to Petunia Mills General Hospital for an overnight stay due to complications following an outpatient procedure. Petunia Mills submitted a claim to Flowery Lanes Health with Ms. Mohair s DOB listed as 9 23 1985. Flowery Lanes Health submitted the encounter to the EDS with Ms. Mohair s DOB listed as 9 23 1885, due to a typographical error. The EDS returned edit 18905 on the MAO-002 report. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20450 Attending Physician is Sanctioned Reject Submitter must ensure that the attending provider was not suspended or terminated from providing services to Medicare beneficiaries during the time(s) of service indicated on the encounter Scenario: Dr. Jernigan, attending physician at Hospice Hotel, made rounds on 1 4 2013, for fellow physician due to an emergency. Hospice Hotel submitted Dr. Jernigan s claim to Better Health. Better Health submitted the encounter to the EDS. Dr. Jernigan s privileges were terminated on 12 20 2012, and he was not authorized to provide services for Hospice patients. Better Health received an MAO-002 report with a reject edit of 20450. 837 Institutional Companion Guide Version 38.0 July 2016. 72 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20455 Operating Provider Is Sanctioned Informational Submitter must ensure that the operating provider was not suspended or terminated from providing surgical services to Medicare beneficiaries during the time(s) of service indicated on the encounter Scenario: Dr. Madhatter performed a cholecystectomy at Highway Hospital on 3 12 2013. Highway Hospital submitted an Institutional claim to Providers Health Plan. Providers Health submitted the encounter to the EDS on 5 6 2013. It was discovered that Dr. Madhatter s operating surgical privileges were suspended on 3 3 2013. The EDS returned the MAO- 002 report to Providers Health with edit 20455. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20515 Immunization Dx Must Align with HCPCS Informational Administration of the Hepatitis B Vaccine must include relevant HCPCS codes and ICD-9 diagnosis code V05.3 (ICD- 10 code Z23 once required) or this edit will post Scenario: Elizabeth C.K. is a patient at Baltimore Metro ESRD facility. Elizabeth recently received the Hepatitis B Vaccine. Baltimore Metro ESRD submitted encounter with HCPCS code 90740 but failed to include diagnosis code V05.3. The EDS posted error code 20515 since the required ICD-9 diagnosis code V05.3 was not included in the encounter for the service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20520 Invalid Ambulance Pick-up Location Informational Encounters for ambulance services must contain a valid nine (9)-digit ZIP code when revenue code 0540 is used and loop 2300 HI01-02 A0. Scenario: Family Health submitted an encounter for ambulance services provided by Monarch Medical Transport, but populated the ambulance pick-up location field (Loop segment 2300 HI01-05) as 9999999.98 (invalid). The EDS will accept the encounter and inform the submitter that a valid ambulance pick up ZIP code is required on all ambulance encounters. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20525 Multiple Ambulance Pick-up Locations Reject Ambulance encounters cannot be submitted containing multiple iterations of loop 2300 HI01-01 BE and HI01-02 A0 Scenario: Round About Health submitted an encounter for ambulance services provided by Maybach Medical Transport. Round About Health submitted the same ZIP code twice for the pick-up location. The EDS rejected the encounter due to multiple ZIP codes listed for the ambulance pick-up location for one (1) patient on the same day. 837 Institutional Companion Guide Version 38.0 July 2016. 73 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 27000 Height or Weight Value Exceeds Limit Reject Encounters submitted with TOB 72X Values for A8 and A9 must be submitted in kilograms. For Value Code A8: Weight must not exceed 318.2 Kg (700 lbs.). For Value Code A9: Height must not exceed 228.6 Kg (7ft 6 in) Scenario: Mr. Nestle Parks, a 432 lb. male, was admitted to Mountain Top Memorial Hospital with kidney failure due to ESRD. River Run Health Plan submitted an encounter to the EDS for services provided to Mr. Parks during his stay at Mountain Top Memorial. The encounter contained Mr. Parks weight in Loop 2300 HI Value Code A8 segment at 432.0. The encounter was rejected with edit 27000 because the A8 value exceeded the allowable value of 318.2 kg. The encounter should have been submitted with Mr. Parks weight identified as 196.36, because the EDS requires that the measurements be populated in kilograms. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17257 Rev Code 091X Not Allowed Informational Medicare no longer accepts Revenue Code 910 for Psychiatric Psychological Services. Ensure that the revenue code submitted for psychiatric services is current and valid. Scenario: Mr. Zane Zany was admitted to Far Side Institution due to severe depression. Way Out There Health Care submitted an encounter on behalf of Far Side Institution populated with revenue code 0910, for services provided to Mr. Zany during his admission from 12 15 2012 to 1 14 2013. The EDPS rejected the encounter submission because, as of October 2003, revenue code 0910 was no longer a valid and acceptable Medicare revenue code. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18730 Invalid Modifier Format Informational Submitter must ensure that the modifier on the encounter is acceptable and valid for EDS submission. Ensure that the format is accurate and the appropriate characters are used. Scenario: Pinky Marvelous was admitted to Check-In Memorial Hospital for a radical mastectomy of her left breast. Check-In Memorial submitted a claim for the surgical procedure to Gallant Health Plan. Gallant Health Plan submitted the encounter to the EDS, populated with CPT 19307, modifier L6. The EDPS posted edit 18730 because the modifier was not entered accurately. The correct submission should be CPT 19307, modifier LT. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22015 Number of Days Conflicts With HH Episode Informational Submitter must ensure that the sum of the from and through dates for the episode of care does not exceed 60 days Scenario: Big Bell Home Health submitted a claim to Whamo Health Plan for Home Health services provided to Major Colonel from 2 3 2013 through 4 17 2013. Whamo Health Plan submitted the encounter to the EDS with the from and through dates of 2 3 2013 through 4 17 2013 on one (1) service line. The encounter was rejected because the episode of care exceeded the required maximum of 60 days. 837 Institutional Companion Guide Version 38.0 July 2016. 74 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22095 Encounter Must Be Submitted on 837-P DME Reject If the NPI on the encounter identifies a DME Supplier, the submitter must use the Payer ID of 80887 to indicate the service is for DMEPOS. Note: When the Payer ID must be changed for an encounter submitted to the EDS, MAOs and other entities must first void the original encounter, then submit a new encounter with the correct Payer ID. Scenario: Reach Rehab submitted an encounter for an electric hospital bed provided for Mr. Anton upon his discharge from Meyers Medical Center. Reach Rehab Services submitted the encounter to the EDS using the Institutional payer ID of 80882.The encounter was rejected because, although Mr. Anton was discharged from the hospital and received care that would be submitted on an Institutional encounter, services provided by Reach Rehab were specific to DMEPOS. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22135 Multiple Rev Code 0023 Lines Present Reject TOB 32X Home Health encounters must not contain more than one (1) service line containing revenue code 0023. Only one (1) revenue code is defined for each prospective payment system that requires HIPPS codes. Scenario: Harmony Home Health submitted an encounter with two (2) service lines containing HIPPS codes HBFK2 and HAEJ1. Harmony Home Health submitted separate revenue code 0023 service lines for each HIPPS code service line. The EDS rejected the encounter because revenue code 0023 may not be used more than once on a single Home Health encounter in conjunction with HIPPS codes. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22225 Missing Provider Specific Record Reject Encounter was submitted that contains a provider NPI that is not identified in the EDPS provider tables as a participating Medicare provider. Scenario: Ipse Institutional Hospital submitted an encounter file to the EDS for an inpatient procedure performed by Dr. Wymee using NPI 0000000000. The EDPS rejected the encounter because Dr. Wymee was not identified in the EDS as a participating Medicare provider. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22020 Conflict Between CC and OSC Reject Encounters submitted with condition code C3 (Partial Approval) must contain Occurrence Span Code (OSC) MO to indicate the service dates that were approved. Scenario: Blue Bellman was admitted to The Best Nursing Facility on 3 3 2013 and discharged on 4 26 2013. The Quality Improvement Organization (QIO) reviewed the claim submitted to Service Plus Health Plan by The Besting Nursing Facility and denied service dates from 4 3 2013 through 4 26 2013. Service Plus Health Plan submitted the approved dates of service (DOS) using condition code C3, but did not populate the encounter with the MO modifier to indicate that the 3 3 2013 through 4 2 2013 DOS were approved. 837 Institutional Companion Guide Version 38.0 July 2016. 75 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21951 No OSC 70 or Covered Days Less Than 3 Informational Skilled Nursing Facility (SNF) encounters submitted using revenue code 0022 and TOB 21X, 22X, or 23X must include the submission of Occurrence Span Code 70 to indicate the dates of a qualifying hospital stay of at least three (3) consecutive days, which qualifies the beneficiary for SNF service. Scenario: Stay With Us Nursing Care submitted a claim to Cornerstone Health Care for Mr. Bobst s SNF stay from 5 3 2013 through 5 13 2013. Cornerstone Health Care submitted the encounter to the EDS using OSC 70; however, due to a data entry error, the from and through dates on the encounter were 5 3 2013, indicating a one day service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17085 CC 40 Required for Same Day Transfer Reject Encounters submitted with TOB 11X and a patient status code of 02, 03, 05, 50, 51, 61, 62, 63, 65, 66, or 70; and the admission date is equal to the statement covers through date must contain Condition Code 40. Scenario: Wendy Wonder was admitted to Healthy Hospital on the morning of 2 21 2013 for a fall due to hallucinations. Healthy Hospital transferred Ms. Wonder to their inpatient psychiatric unit on the evening of 2 21 2013. Health Hospital submitted Ms. Wonder s claim to Wholeness Health using a patient status code of 65 (Discharged Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital) without providing the required Condition Code 40. Wholeness Health adjudicated the claim and submitted the encounter to the EDS. The EDPS rejected the encounter because inpatient hospital encounters populated with patient status code 65 must also contain Condition Code 40 to indicate that Ms. Wonder was admitted and discharged on the same date. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22280 Rev Code 277 Invalid for a HH Reject Home Health encounters cannot be submitted using revenue code 277(Medical surgical supplies oxygen (take home)). Scenario: Fawn Home submitted a claim to Hulu Health Care for provision of oxygen to Cletus Clapp, using revenue cod 0023 for the home health service and revenue code 277 for the supply service. Hulu Health Care adjudicated the claim and submitted the encounter to the EDS. Home Health received an MAO-002 report rejecting the encounter with edit 22280 because revenue code 277 is not a Medicare acceptable revenue code. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18710 Missing Invalid POA Indicator Reject Encounter type requires that an indicator of Y or N for Present on Admission according to NUBC requirements, but the indicator is not populated or is inaccurate for the data provided in the encounter. Scenario: Miss Ames was admitted to Hope Hospital for a stroke and a cerebral infarction with complications on 3 26 2013. She was discharged on 4 5 2013. Hope Hospital submitted a claim to Mount Vios for Miss Ames hospital admission. Hope Hospital submitted an encounter to the EDS that did not include the required POA indicator of Y due to the diagnoses populated on the encounter. The EDS rejected the encounter with error code 18710. 837 Institutional Companion Guide Version 38.0 July 2016. 76 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21925 Swing Bed SNF Conditions Not Met Reject Encounter submitted with TOB 18X or 21X with Revenue Code 0022 and Occurrence Span Code 70 is not present or Occurrence Code 50 is not present for each submission of Revenue Code 0022. Scenario: Riverwalk Rehab, a Skilled Nursing Facility, submitted a claim to Haven Health Care for Mr. Benson s admission, following his transfer after a ten (10) day stay at Marco General Hospital. Haven Health submitted an encounter to the EDS using TOB 21X, Revenue Code 0022, and the required Occurrence Span Code of 70, which indicated Mr. Bensons inpatient hospital stay of three (3) days or greater. The EDS rejected the encounter with error code 21925 because it did not also include the Occurrence Code of 50, which is required for each service line submitted for Revenue Code 0022. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22405 Occurrence Code 55 DOD Required Reject When patient discharge status code is 20 (expired), 40 (expired at home), 41 (expired in a medical facility), or 42 (expired place unknown), submitter must ensure that Occurrence Code 55 and the date of death are present. Scenario: Gentle HealthCare submitted a final claim to Monument Medical Health Plan for Mr. G. Barnes, who expired on 9 15 2013. Monument Medical Health submitted and encounter to the EDS with a patient discharge status code of 41 in Loop 2300 CL103, but the Occurrence Code and Date of Death (occurrence code date) were not provided. The EDS rejected the encounter on the MAO-002 Report with error code 22405. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17100 DOS Required for HH Encounter Reject Home Health encounters submitted with Revenue Codes 42X-44X and 55X-59X must contain dates of service for the revenue code line. Scenario: Tympany Home Health submitted an encounter to the EDS for physical therapy services (Revenue Code 42X) provided during a Home Health episode of care to Mrs. Waterman from 8 3 2013 through 8 31 2013. The encounter was rejected with error code 17100 because, although the dates of service were populated on the encounter header level, the revenue code line did not contain the physical therapy service dates. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00175 Verteporfin Reject Encounters submitted with TOB 13X or 85X for Ocular Photodynamic Tomography with Verteporfin must contain the same dates of service for the combination of these services, with the appropriate ICD-9 and ICD- 10 diagnosis codes. Submitter must also ensure that the procedures are valid for the dates of service. Scenario: Dr. Cuff conducted an OPT with Verteporfin (J3396 and 67225) for Mr. Jay Bird as treatment for Mr. Bird s diagnosis of atrophic macular degeneration (362.51). The encounter was submitted to the EDS by Strideways Health and rejected because the diagnosis of 362.51 should not be identified for the service submitted on the encounter. 837 Institutional Companion Guide Version 38.0 July 2016. 77 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00750 Service(s) Not Covered Prior To 4 1 2013 Reject Encounters submitted for Ventricular Assist Devices (VADs) supplies accessories with procedure code Q0507, Q0508, or Q0509 must contain dates of service on or after 4 01 2013 Scenario: Dr. Zhivago s office submitted a claim to Healthy Heart Health Plan for a battery and battery charger provided to Mr. Joe Schmeaux following the attachment of his VAD on 2 3 2013. Healthy Heart submitted an encounter to the EDS using Q0507. The EDS rejected the encounter with error code 00750 because Q0507 was not an effective code for DOS prior to 4 1 2013. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22320 Missing ASC Procedure Code Informational The procedure codes present on TOB 83X encounter service lines cannot be located in the ASC Fee Schedule or ASC Drug Fee Schedule. Scenario: Flex Medical ASC submitted a TOB 83X encounter to the EDS with procedure code G0261 (prostate brachytherapy), which is not listed in the ASC Fee Schedule. The EDPS posted error 22320 because procedure code G0261 is not an acceptable procedure code in an ASC setting. TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE | /kaggle/input/edi-db-835-837/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_2 |
Gentle HealthCare submitted a final claim to Monument Medical Health Plan for Mr. G. Barnes, who expired on 9 15 2013. Monument Medical Health submitted and encounter to the EDS with a patient discharge status code of 41 in Loop 2300 CL103, but the Occurrence Code and Date of Death (occurrence code date) were not provided. The EDS rejected the encounter on the MAO-002 Report with error code 22405. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17100 DOS Required for HH Encounter Reject Home Health encounters submitted with Revenue Codes 42X-44X and 55X-59X must contain dates of service for the revenue code line. Scenario: Tympany Home Health submitted an encounter to the EDS for physical therapy services (Revenue Code 42X) provided during a Home Health episode of care to Mrs. Waterman from 8 3 2013 through 8 31 2013. The encounter was rejected with error code 17100 because, although the dates of service were populated on the encounter header level, the revenue code line did not contain the physical therapy service dates. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00175 Verteporfin Reject Encounters submitted with TOB 13X or 85X for Ocular Photodynamic Tomography with Verteporfin must contain the same dates of service for the combination of these services, with the appropriate ICD-9 and ICD- 10 diagnosis codes. Submitter must also ensure that the procedures are valid for the dates of service. Scenario: Dr. Cuff conducted an OPT with Verteporfin (J3396 and 67225) for Mr. Jay Bird as treatment for Mr. Bird s diagnosis of atrophic macular degeneration (362.51). The encounter was submitted to the EDS by Strideways Health and rejected because the diagnosis of 362.51 should not be identified for the service submitted on the encounter. 837 Institutional Companion Guide Version 38.0 July 2016. 77 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00750 Service(s) Not Covered Prior To 4 1 2013 Reject Encounters submitted for Ventricular Assist Devices (VADs) supplies accessories with procedure code Q0507, Q0508, or Q0509 must contain dates of service on or after 4 01 2013 Scenario: Dr. Zhivago s office submitted a claim to Healthy Heart Health Plan for a battery and battery charger provided to Mr. Joe Schmeaux following the attachment of his VAD on 2 3 2013. Healthy Heart submitted an encounter to the EDS using Q0507. The EDS rejected the encounter with error code 00750 because Q0507 was not an effective code for DOS prior to 4 1 2013. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22320 Missing ASC Procedure Code Informational The procedure codes present on TOB 83X encounter service lines cannot be located in the ASC Fee Schedule or ASC Drug Fee Schedule. Scenario: Flex Medical ASC submitted a TOB 83X encounter to the EDS with procedure code G0261 (prostate brachytherapy), which is not listed in the ASC Fee Schedule. The EDPS posted error 22320 because procedure code G0261 is not an acceptable procedure code in an ASC setting. TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22340 ESRD Diagnosis Code Missing Reject ERSD encounters (TOB 72X) must use the ESRD-related ICD-9 or ICD-10 diagnosis codes based on DOS (i.e., ICD-9 prior to 10 01 2015; ICD-10 on or after 10 01 2015). Scenario: On 10 15 2015, Health4U submitted an encounter to the EDS with bill type 72X for Feng Li s consultation with Dr. Jones on 9 1 2015 with ICD-10 diagnosis code N18.2 Chronic Kidney Disease, Stage 2 (Mild). The EDPS rejected the encounter because the DOS submitted on the encounter requires the use of ICD-9 diagnosis codes. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22355 Inpatient Service Line Error Reject EDPS will reject Institutional inpatient encounters (TOB 11X, 18X, 21X, and 41X) at the header level when any of the associated service lines have been rejected. MAOs must correct the service line errors and resubmit the encounter. Scenario: On 6 28 2015, Care Bear Health resubmitted an encounter to the EDS with bill type 21X and a billed amount of 240.00 on the Revenue Code 0022 service line. The EDS previously rejected the encounter and returned an MAO-002 Report containing error code 21979 Charges for Rev Code 0022 Must Be Zero because the Revenue Code service line billed amount and non-covered charge amounts must be either blank or equal to zero. The adjusted encounter received error code 22355 at the header level because it contained a reject error on the service line. 837 Institutional Companion Guide Version 38.0 July 2016. 78 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22390 HIPPS Code Required for SNF HH Reject Encounters must contain HIPPS codes when submitted with TOB 18X or 21X and Revenue Code 0022 or TOB 32X and Revenue Code 0023. Note: This edit will post as a reject only for DOS on or after 7 1 2014. Scenario: Lamplight Home Health submitted an encounter to the EDS containing TOB 32X (Home Health Inpatient), Revenue Code 0023, and procedure code G0154(x2). The encounter did not contain a HIPPS code on the Revenue Code 0023 service line. The EDS returned the encounter with error code 22390, because all Home Health encounters must be submitted with appropriate HIPPS codes. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22395 HIPPS Code Conflicts with Revenue Code Reject Encounters must contain the appropriate HIPPS code for the service submitted. Revenue Code 0022 must contain appropriate SNF HIPPS codes. Revenue Code 0023 must contain appropriate HH HIPPS codes. Note: This edit will post as a reject only for DOS on or after 7 1 2014. Scenario: Pink Lady Nursing Care submitted a claim to Aurelia Health Plan for SNF services provided for Ms. Jamella Fantastic. Aurelia Health Plan submitted the encounter to the EDS with TOB 21X, Revenue Code 0022 and HIPPS code HAEK2. The EDS returned the encounter with error code 22395, because the HIPPS code populated on the encounter indicated a Home Health service instead of a Skilled Nursing Facility service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22400 HP Qualifier Must Exist for HIPPS Code Reject Encounters submitted with TOB 18X or 21X and Revenue Code 0022 or TOB 32X and Revenue Code 0023 must contain a value of HP in the SV202-1 element for HIPPS codes. Note: This edit will post as a reject only for DOS on or after 7 1 2014. Scenario: Serenity Care Nursing submitted a claim to Universal Medical Health Plan for Mr. Bacchus two (2) week stay at their Skilled Nursing Facility. Universal Medical Health Plan submitted the encounter to the EDS with the appropriate HIPPS codes; however, the qualifier was populated with HC (procedure code qualifier). TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22410 Invalid Service(s) for TOB Reject Encounters submitted for Ventricular Assist Devices (VADs) supplies and accessories with procedure codes must only contain specific bill types (12X, 13X, 22X, 23X, 32X, 33X, 34X, 74X, or 85X). Note: TOB 33X is not applicable on or after 10 1 2013 Scenario: Dr. Pandora submitted a claim to Healthy Heart Health Plan for wound care and dressings provided after Mr. Jingleheimer s pacemaker insertion. The encounter was submitted to the EDS with TOB 14X. The encounter was rejected with error code 22410, because VAD supplies and accessories cannot be submitted with this bill type. 837 Institutional Companion Guide Version 38.0 July 2016. 79 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22415 Revenue code 0274 Required Reject Encounters submitted for Ventricular Assist Devices (VADs) supplies accessories with procedure code Q0507, Q0508, or Q0509 must contain Revenue Code 0274 and the appropriate bill types (12X, 13X, 22X, 23X, 32X, 33X, 34X, 74X, or 85X). Scenario: Karma Health submitted an encounter to the EDS for VAD replacement leads using Revenue Code 0022. The encounter was rejected with error code 22415 because Revenue Code 0274 is the only appropriate code for submission of VAD supplies and accessories. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22420 TOB 33X Invalid for DOS Reject Encounters submitted with dates of service (DOS) on or after 10 01 2013 must not contain TOB 33X. Scenario: Strong s Home Care submitted an encounter with TOB 33X (Home Health Outpatient) to the EDS for Home Health services provided for Mr. V. Triumph from November 3, 2013 through 11 18 2013. The EDS rejected the encounter and returned an MAO-002 report with error code 22420, because TOB 33X was deactivated for all DOS on or after 10 1 2013. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18500 Multiple CPT HCPCS for Same Service Informational Encounters cannot be submitted with multiple procedure codes to identify the same service procedure. Scenario: ProHealth submitted an encounter to the EDS with procedure code 15839 (labiaplasty) performed on Ms. Cross on 11 13 2013. The EDS returned an MAO-002 report to ProHealth with error code 18500 because ProHealth had already submitted another encounter for the same dates of service for Ms. Cross with procedure code 56620 (labiaplasty). Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20500 Invalid DOS for Rev Code Billed Reject Encounter s Revenue Code service date must be within the range of the procedure service line DOS when submitting: a)TOB 71X, 75X, or 77X with a valid Revenue Code; b) Revenue Code 054X with TOBs 13X, 22X, 23X, 83X, or 85X; c) Revenue Codes 042X, 43X, 044X, or 047X with TOBs 12X, 13X, 22X, 23X, 74X, or 83X; d) Revenue Code 047X with TOB 34X; or e) Revenue Codes within the range of 0300-0319 with HCPCS Codes 78267, 78268,80002-89399, or G0000- G9999 and TOBs 13X, 14X, 23X, 72X, 83X, or 85X Scenario: Pink Acres Health Clinic submitted a claim to Way Out Health Plan for behavioral health services provided to Cookie Triton from 3 26 2013 through 4 12 2013. Way Out Health Plan submitted an encounter to the EDS with TOB 71X and Revenue Code 0900 with procedure service line DOS of 3 26 15 4 12 15 and Revenue Code service dates of 4 26 15 5 12 15. The EDS rejected the encounter because the Revenue Code service dates were not valid for the dates of the service provided. 837 Institutional Companion Guide Version 38.0 July 2016. 80 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21979 Charges for Rev Code 0022 Must Be Zero Reject For encounters submitted with TOB 18X or 21X and Revenue Code 0022, the billed amount (Loop 2400 SV203) and non- covered charge amount (Loop 2400 SV207) should equal zero when these fields are populated for the Revenue Code service line. Scenario: Mohair Nursing Camp submitted a claim to Fancy Free Health Plan for services provided to Curly Sue Skumptik. Fancy Free Health Plan submitted an encounter for the services to the EDS containing a billed amount of 240.00 on the Revenue Code 0022 service line. The EDS rejected the encounter and returned an MAO-002 Report containing error code 21979 because the Revenue Code service line billed amount and non-covered charge amounts must be either blank or equal to zero. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 98300 Exact Inpatient Duplicate Encounter Reject MAOs must submit replacement or void encounters when altering Inpatient encounters. The EDPS will reject Inpatient encounters submitted with bill types 11X, 18X, 21X, or 41X that contain duplicate header level (loop 2300) data elements for the HICN, DOS, TOB, and Billing Provider NPI of an existing accepted and stored encounter. Scenario: On 8 3 2015, A Fine MAO submitted an encounter for Mayank Deshpande s stay at Mercy Hospital from 6 15 2015 through 6 23 2015. On 8 10 2015, A Fine MAO resubmitted the same encounter as an original to the EDPS with altered procedure modifiers. The EDPS rejected the encounter submitted on 8 10 2015 because the header level (loop 2300) HICN, DOS, TOB, and Billing Provider NPI data values matched those of the previous encounter submitted on 8 3 2015. If the provider wishes to adjust the line level (loop 2400) elements, they must submit a replacement encounter or void the original encounter then resubmit. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 98315 Linked Chart Review Duplicate Reject Linked Chart Review encounters cannot be submitted where the HICN, Associated ICN, header DOS, diagnosis code(s) and TOB contain the exact same values as another Chart Review encounter already present within the EODS. Scenario: Sequoia Health Plan conducted an audit of Langhorne Hospital and discovered an encounter previously submitted to the EDS contained an unnecessary diagnosis code. On 4 01 2014, Sequoia Health Plan submitted a linked chart review encounter to the EDS containing the associated ICN of the original encounter to identify the unnecessary diagnosis code. On 5 01 2014 Sequoia Health Plan inadvertently submitted the exact same linked chart review encounter to the EDS. The EDS rejected the second submission of the linked chart review encounter because no changes were detected between the two (2) linked chart review encounters. 837 Institutional Companion Guide Version 38.0 July 2016. 81 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 98320 Chart Review Duplicate Reject Unlinked Chart Review encounters cannot be submitted where the HICN, header DOS, diagnosis code(s) and TOB contain the exact same values as another Chart Review encounter already present within the EODS. Scenario: Ohio Health Plan conducted an audit of Cincinnati City Hospital and discovered an encounter not previously submitted to the EDS required an additional diagnosis code. On 3 15 2014, Ohio Health Plan submitted an unlinked chart review encounter to the EDS to include the additional diagnosis code. On 6 01 2014, Ohio Health Plan submitted the same unlinked chart review encounter to the EDS due to a clerical error. The EDS rejected the second submission of the unlinked chart review encounter because the EDS detected no changes between the two (2) unlinked chart review encounters. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00030 ICD-10 Dx Not Allowed Reject ICD-10 diagnosis and or procedure codes cannot be submitted for inpatient or home health encounters with Through DOS prior to 10 01 2015 or outpatient encounters with a From DOS prior to 10 1 2015. ICD-9 codes are required. Scenario: Arthur Home Health submitted an encounter (TOB 32X) for Elizabeth Door with DOS from 11 15 2014 through 11 20 2014 with a primary diagnosis code of C509.19 (Malignant Neoplasm of Unspecified Site). The EDS rejected the encounter because an ICD-10 diagnosis code was reported prior to the established transition date to ICD-10 codes. The encounter must be updated with ICD-9 diagnosis code 174.9 and resubmitted to the EDS. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00035 ICD-9 Dx Not Allowed Reject ICD-9 diagnosis and or procedure codes cannot be submitted for inpatient or home health encounters with Through DOS on or after 10 01 2015 or outpatient encounters with a From DOS on or after to 10 1 2015. ICD- 10 codes are required. Scenario: Arthur Home Health submitted an encounter (TOB 32X) for Elizabeth Door with DOS from 12 03 2015 through 12 10 2015 with a primary diagnosis code of 174.9 (Malignant Neoplasm of Breast (Female) Unspecified Site). The EDS rejected the encounter because an ICD-9 diagnosis code was reported after the established transition date to ICD-10 codes. The encounter must be updated with ICD-10 diagnosis code C509.19 and resubmitted to the EDS. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00775 Unable to Adjust Rejected Encounter Reject MAOs cannot submit a replacement encounter that links to a rejected encounter stored in the EODS. Scenario: Torchlight Healthcare submitted an encounter for services provided to James Miramar by Dr. Gavin, and received ICN 5555555555552. The EDPS rejected the encounter due to invalid beneficiary information. Dr. Gavin s staff identified the need to adjust the payment amount, and sent the corrected payment information to Torchlight Healthcare. Torchlight Healthcare submitted the replacement encounter, containing the corrected payment amount, to the EDPS prior to reconciling the MAO-002 report that identified the original encounter as a rejected encounter. The EDPS rejected the replacement encounter because the original encounter stored in the EODS with ICN 5555555555552 had been rejected. 837 Institutional Companion Guide Version 38.0 July 2016. 82 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00780 Adjustment Must Match Original Reject When submitting a replacement or void encounter, MAOs must match the ICN, HICN, Last Name, First Name, Payer ID, and TOB header data elements of an accepted encounter stored in the EODS. Note: The EDPS will validate the beneficiary s demographic data (HICN, Last Name, First Name) according to the Medicare Beneficiary Database (MBD), as well as validate the beneficiary s Billing Provider NPI prior to posting edit 00780 Scenario: Torchlight Healthcare submitted an encounter totaling 250 for services provided to Ciao Bella by Grammar City Hospital, and received ICN 5555555555557. Grammar City Hospital resubmitted the encounter to correct the payment amount to 205, to Torchlight Healthcare under a new Payer ID. Torchlight Healthcare submitted the replacement encounter to the EDPS with the corrected payment information and the patient s new Payer ID. The EDPS rejected the replacement encounter because the patient s Payer ID did not match that of the stored encounter in the EODS or the MBD. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00785 Linked Encounter Not in EODS Reject The ICN referenced in a linked chart review must match the ICN of an accepted encounter stored in the EODS. Scenario: ABC Health Plan submitted an encounter for Janice Wei, and received ICN 1231234564569. As a result of a routine medical record review 6 months later, ABC Health Plan submitted a linked chart review encounter referencing ICN 1231234564568 to add a diagnosis code. The EDPS rejected the chart review encounter because there was not an existing, accepted encounter with ICN 1231234564568 stored in the EODS. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00790 Linked Encounter is Voided Adjusted Reject The ICN referenced in a linked chart review must not match the ICN of a voided encounter stored in the EODS. Scenario: ABC Health Plan submitted an encounter for Emanuel Spice, and received ICN 1234567890123. ABC Health Plan discovered the encounter was submitted in error and submitted a void request to the EDS three months following the original submission. After a chart audit a year later, ABC Health Plan submitted a linked chart review encounter referencing ICN 1234567890123 to delete an incorrectly reported diagnosis code. The EDPS rejected the chart review encounter because the encounter stored in the EODS with ICN 1234567890123 was voided. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00795 Linked Encounter is Rejected Reject The ICN referenced in a linked chart review must not match the ICN of a rejected encounter stored in the EODS. Scenario: ABC Health Plan submitted an encounter for Shaunna Brookstone, and received ICN 4561234561232. The EDPS rejected the encounter due to invalid beneficiary information populated on the encounter. As a result of a routine medical record review a year later, ABC Health Plan submitted a linked chart review encounter referencing ICN 4561234561232 to add diagnoses. The EDPS rejected the chart review encounter because the encounter stored in the EODS with ICN 4561234561232 was rejected. 837 Institutional Companion Guide Version 38.0 July 2016. 83 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 03015 HCPCS Code Invalid for DOS Reject Prior to encounter submission, the submitter should verify that the procedure code is valid effective for the DOS populated on the encounter. Scenario: Oxford Hospital submits an encounter on 3 01 2013 for Chance Borny for a DOS 2 17 2013 which included HCPCS code G0290. The EDS will report error code 03015 with a reject status on the MAO-002 report because HCPCS code G0290 was terminated 12 31 2012. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 03022 Invalid CMG for IRF Encounter Reject TOB 11X Inpatient Rehabilitation Facility encounter service lines billed with Revenue Code 0024 must contain acceptable HIPPS codes. Scenario: Duane Max suffered a minor stroke and is recovering at Summer Rehab Facility. Summer Rehab submitted a TOB 11X encounter with a service line containing Revenue Code 0024 and HIPPS code 1BFLS. The EDPS posted edit 03022 since HIPPS code 1BFLS is invalid and A0101 (Stroke with Motor 51.05 w o comorbidities) should have been entered on the service line containing Revenue Code 0024, based on the HIPPS assessment performed. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 03102 Invalid Provider Type Specialty Informational The EDPS derives the Provider Specialty based on Provider s Address. Ensure the correct Provider Address is included on the encounter relevant to the services rendered. Scenario: Revive Center is an Independent Diagnostic Testing Center (provider specialty code 47) that contains a Mammography Screening Center (provider specialty code 45). Routine diagnostic tests were performed on Mr. Keene; however, the tests were billed under the location address for Provider Specialty code 45 rather than 47. The EDPS will post error code 03102 for this encounter due to the use of the wrong specialty code on the encounter. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 03165 Telehealth Facility Fee Not Allowed Reject Institutional Telehealth encounter service lines containing procedure code Q3014 (Telehealth Originating Site Facility Fee) must include revenue code 078X (telemedicine) and one (1) of the following bill types: 12X, 13X, 22X, 23X, 71X, 72X, 76X, 77X, or 85X. Scenario: Dr. Smith, working through Century Hospital, used the Telehealth option to follow-up with patient Saqib Murray. Dr. Smith submitted a Telehealth encounter service line with procedure code Q3014, revenue code 0780, and bill type 11X to the MAO, 4YourHealth. 4YourHealth submitted the encounter to the EDS. The EDPS rejected the service line because bill type 11X is not an accepted bill type for the Telehealth Originating Site Fee. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20495 Revenue Code Is Non-Billable for TOB Reject Encounters with TOB 22X with certain revenue codes will receive this edit. Scenario: Skilled Nursing Facility Summit Peak submits a TOB 22X encounter incorrectly containing a service with revenue code 0944 Drug Rehabilitation. The EDS will report error code 20495 because revenue code 0944 is not permitted on TOB 22X encounters. 837 Institutional Companion Guide Version 38.0 July 2016. 84 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22430 HCPCS Codes with Invalid TOB Reject Encounters with TOB 22X or 23X billed with the following HCPCS codes will receive this edit: G0446, G0442, G0443, G0444, and G0447. Scenario: Skilled Nursing Facility Summit Peak submits a TOB 22X encounter incorrectly containing a service with HCPCS code G0442 Annual Alcohol Misuse Screening 15 Minutes. The EDS will report error code 22430 because HCPCS code G0442 is not permitted on TOB 22X or 23X encounters. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22375 Item Service Not Covered For RHC Reject All FQHC encounter service lines must contain only qualified FQHC services. Scenario: Top Care Health Plan submits a TOB 71X encounter incorrectly containing a service with revenue code 030X (Lab). The EDS will reject this encounter with error code 22375 because revenue code 030X is not permitted for submission in conjunction with TOB 71X. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00800 Parent ICN Not Allowed for Original Reject An original, non-chart review encounter should not contain a a linked ICN. Scenario: Southwest Health Plan submitted an original, non-chart review encounter for Samuel Anderson. The original, non-chart review encounter contained a reference to ICN 4561234561233. The EDPS rejected the encounter because an original, non-chart review encounter should not contain an ICN. The original encounter should be resubmitted without the ICN. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00805 Deleted Diagnosis Code Not Allowed Reject An unlinked chart review encounter should not be submitted with an indicator for deleting diagnosis code(s). OR A replacement chart review encounter for a previously accepted unlinked chart review encounter should not be submitted with an indicator for deleting diagnosis code(s). Scenario 1: Southwest Health Plan submitted an unlinked chart review encounter (i.e., a chart review encounter without an ICN reference). The original unlinked chart review contains the indicator for deleting a diagnosis code (REF01 EA REF02 8 ). The EDPS rejected the original, unlinked chart review encounter because no reference to an existing diagnosis code exists for deletion. Scenario 2: Southwest Health Plan submitted a replacement chart review encounter (frequency code 7 ) for a previously accepted unlinked chart review encounter (i.e., a chart review encounter without an ICN reference). The replacement chart review encounter includes an indicator for deleting a diagnosis code (REF01 EA REF 03 8 ). The EDPS rejected the replacement chart review encounter because EDPS does not allow deletion of a diagnosis from an unlinked chart review. To delete a diagnosis code from an unlinked chart review, the plan should void the existing unlinked chart review and resubmit without the diagnosis code. 837 Institutional Companion Guide Version 38.0 July 2016. 85 11.0 Submission of Default Data in a Limited Set of Circumstances MAOs and other entities may submit default data in a limited set of circumstances, as identified and explained in Table 19. MAOs and other entities cannot submit default data for any circumstances other than those listed in the table below. CMS will use this interim approach for the submission of encounter data. In each circumstance where default information is submitted, MAOs and other entities are required to indicate in Loop 2300, NTE01 ADD, NTE02 the reason for the use of default information. If there are any questions regarding appropriate submission of default encounter data, MAOs and other entities should contact CMS for clarification. CMS will provide additional guidance concerning default data, as necessary. 11.1 Default Data Reason Codes (DDRC) Loop 2300, NTE02 allows for a maximum of 80 characters and one (1) iteration, which limits the submission of default data to one (1) message per encounter. In order to allow the population of multiple default data messages in the NTE02 field, CMS will use a three (3)-digit default data reason code (DDRC), which will map to the full default data message in the EDS. MAOs and other entities may submit multiple DDRCs with the appropriate three (3)-digit DDRC. Multiple DDRCs will be populated in a stringed sequence with no spaces or separators between each DDRC (i.e., 036040048). Table 19 provides the CMS approved situations for use of default data, the default data message, and the default data reason code. TABLE 19 DEFAULT DATA DEFAULT DATA DEFAULT DATA MESSAGE (NTE02) DEFAULT DATA REASON CODE Rejected Line Extraction REJECTED LINES CLAIM CHANGE DUE TO REJECTED LINE EXTRACTION 036 Medicaid Service Line Extraction MEDICAID CLAIM CHANGE DUE TO MEDICAID SERVICE LINE EXTRACTION 040 EDS Acceptable Anesthesia Modifier MODIFIER CLAIM CHANGE DUE TO EDS ACCEPTABLE ANESTHESIA MODIFIER 044 Default NPI for atypical providers NO NPI ON PROVIDER CLAIM 048 Default EIN for atypical providers NO EIN ON PROVIDER CLAIM 052 Chart Review Default Procedure Codes DEFAULT PROCEDURE CODES INCLUDED IN CHART REVIEW 056 True COB Default Adjudication Date DEFAULT TRUE COB PAYMENT ADJUDICATION DATE 060 Default NPIs should only be submitted to the EDS when the provider is considered atypical. An atypical provider is defined as an individual or business that bills for services rendered but does not meet the definition of a healthcare provider according to the NPI Final Rule 45 CFR 160.103 (e.g., non- emergency transportation providers, Meals on Wheels, personal care services, etc.). Default EIN should only be submitted to the EDS when the provider is considered atypical. 837 Institutional Companion Guide Version 38.0 July 2016. 86 12.0 Tier II Testing CMS developed the Tier II testing environment to ensure that MAOs and other entities have the opportunity to test a more inclusive sampling of their data. MAOs and other entities that have obtained end-to-end certification may submit Tier II testing data. CMS encourages MAOs and other entities to utilize the Tier II testing environment when they have questions or issues regarding edits received on EDFES Acknowledgement Reports or MAO-002 Encounter Data Processing Status reports; and when they have new submission scenarios that they wish to test prior to submitting to production. MAOs and other entities may submit chart review, replacement or void encounters to the Tier II testing environment only when the encounters are linked to previously submitted and accepted encounters in the Tier II testing environment. Encounter files submitted to the Tier II testing environment must comply with the TR3, CMS 5010 Edits Spreadsheets, and the CMS EDS Companion Guides, as well as the following requirements: Files must be identified using the Authorization Information Qualifier data element Additional Data Identification in the ISA segment (ISA01 03). Files must be identified using the Authorization Information data element to identify the Tier II indicator in the ISA segment (ISA02 8888888888). Files must be identified as Test in the ISA segment (ISA15 T). Submitters may send multiple Contract IDs per file Submitters may send multiple files for a Contract ID, as long as each file does not exceed 2,000 encounters per Contract ID If any Contract ID on a given file exceeds 2,000 encounters during the processing of the file, the entire file will be returned As with production encounter data, MAOs and other entities will receive the TA1, 999, and 277CA Acknowledgement Reports and the MAO-002 Reports. While not required, MAOs and other entities are strongly encouraged to correct errors identified on the reports and resubmit data. 837 Institutional Companion Guide Version 38.0 July 2016. 87 13.0 EDS Acronyms Table 20 below outlines a list of acronyms that are currently used in EDS documentation, materials, and reports distributed to MAOs and other entities. This list is not all-inclusive and should be considered a living document; as acronyms will be added, as required. TABLE 20 EDS ACRONYMS ACRONYM DEFINITION A N A ASC Ambulatory Surgery Center C N A CAH Critical Access Hospital CARC Claim Adjustment Reason Code CAS Claim Adjustment Segments CC Condition Code CCI Correct Coding Initiative CCN Claim Control Number CEM Common Edits and Enhancements Module CMG Case Mix Group CMS Centers for Medicare Medicaid Services CORF Comprehensive Outpatient Rehabilitation Facility CPO Care Plan Oversight CPT Current Procedural Terminology CRNA Certified Registered Nurse Anesthetist CSC Claim Status Code CSCC Claim Status Category Code CSSC Customer Service and Support Center D N A DCN Document Control Number DDRC Default Data Reason Code DME Durable Medical Equipment DMEPOS Durable Medical Equipment, Prosthetics, Orthotics, and Supplies DMERC Durable Medical Equipment Carrier DOB Date of Birth DOD Date of Death DOS Date(s) of Service E N A E M or E M Evaluation and Management EDDPPS Encounter Data DME Processing and Pricing Sub-System EDFES Encounter Data Front-End System EDI Electronic Data Interchange EDIPPS Encounter Data Institutional Processing and Pricing Sub-System EDPPPS Encounter Data Professional Processing and Pricing Sub-System EDPS Encounter Data Processing System EDR Encounter Data Record 837 Institutional Companion Guide Version 38.0 July 2016. 88 ACRONYM DEFINITION EDS Encounter Data System EIC Entity Identifier Code EODS Encounter Operational Data Store ESRD End Stage Renal Disease F N A FFS Fee-for-Service FQHC Federally Qualified Health Center FTP File Transfer Protocol FY Fiscal Year H N A HCPCS Healthcare Common Procedure Coding System HHA Home Health Agency HICN Health Information Claim Number HIPAA Health Insurance Portability and Accountability Act HIPPS Health Insurance Prospective Payment System I N A ICD-9CM ICD-10CM International Classification of Diseases, Clinical Modification (versions 9 and 10) ICN Interchange Control Number Internal Control Number IG Implementation Guide IPPS Inpatient Prospective Payment System IRF Inpatient Rehabilitation Facility M N A MAC Medicare Administrative Contractor MAO Medicare Advantage Organization MTP Multiple Technical Procedure MUE Medically Unlikely Edits N N A NCD National Coverage Determination NDC National Drug Codes NPI National Provider Identifier NCCI National Correct Coding Initiative NOC Not Otherwise Classified NPPES National Plan and Provider Enumeration System O N A OASIS Outcome and Assessment Information Set OBRA Omnibus Budget Reconciliation Act of 1993 OCE Outpatient Code Editor OIG Officer of Inspector General OPPS Outpatient Prospective Payment System P N A PACE Programs of All-Inclusive Care for the Elderly PHI Protected Health Information PIP Periodic Interim Payment 837 Institutional Companion Guide Version 38.0 July 2016. 89 ACRONYM DEFINITION POA Present on Admission POS Place of Service PPS Prospective Payment System R N A RAP Request for Anticipated Payment RHC Rural Health Clinic RNHCI Religious Nonmedical Health Care Institution RPCH Regional Primary Care Hospital S N A SME Subject Matter Expert SNF Skilled Nursing Facility SSA Social Security Administration T N A TARSC Technical Assistance Registration Service Center TCN Transaction Control Number TOB Type of Bill TOS Type of Service TPS Third Party Submitter V N A VC Value Code Z N A ZIP Code Zone Improvement Plan Code 837 Institutional Companion Guide Version 38.0 July 2016. 90 TABLE 21 - REVISION HISTORY VERSION DATE DESCRIPTION OF REVISION 2.1 9 9 2011 Baseline Version 3.0 11 16 2011 Release 2 4.0 12 9 2011 Release 3 5.0 12 20 2011 Release 4 6.0 3 8 2012 Release 5 7.0 5 9 2012 Release 6 8.0 6 22 2012 Release 7 9.0 8 31 2012 Release 8 10.0 9 26 2012 Release 9 11.0 11 2 2012 Release 10 12.0 11 26 2012 Release 11 13.0 12 21 2012 Release 12 14.0 1 21 2013 Release 13 15.0 2 26 2013 Release 14 16.0 3 20 2013 Release 15 17.0 4 15 2013 Release 16 18.0 5 20 2013 Release 17 19.0 6 24 2013 Release 18 20.0 7 25 2013 Release 19 21.0 9 26 2013 Release 20 22.0 10 25 2013 Release 21 23.0 11 22 2013 Release 22 24.0 12 27 2013 Release 23 25.0 1 20 2014 Release 24 26.0 2 21 2014 Release 25 27.0 3 18 2014 Release 26 28.0 4 28 2014 Release 27 837 Institutional Companion Guide Version 38.0 July 2016. 91 VERSION DATE DESCRIPTION OF REVISION 29.0 5 30 2014 Release 28 30.0 7 30 2014 Release 29 31.0 9 30 2014 Release 30 32.0 11 28 2014 Release 31 33.0 3 31 2015 Release 32 34.0 6 1 2015 Release 33 35.0 9 4 2015 Release 34 36.0 11 28 2015 Release 35 37.0 3 25 2016 Release 36 38.0 7 8 16 Section 3.1 Removed Limitations in Connectivity Table 38.0 7 8 16 Section 6.7, Table 10 Added new EDFES notification 38.0 7 8 16 Section 7.0, Table 11 Added new deactivated EDFES edit 38.0 7 8 16 Section 10.0, Table 14 Updated to include new edits (00800, 00805, and 22375). Updated disposition for error code 18730 to informational. 38.0 7 8 16 Section 10.0, Table 15 Updated to include new edits (00800,00805, 18730, and 22375). 38.0 7 8 16 Section 10.2.3, Table 17 Updated EDPPPS Edits Prevention and Resolution Strategies to include scenarios for new edits (00800, 00805 and 22375). | /kaggle/input/edi-db-835-837/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_3 |
Stedi maintains this guide based on public documentation from Health Partner Plans. Contact Health Partner Plans for official EDI specifications. To report any errors in this guide, please contact us. X12 837 Health Care Claim: Institutional (X223A3) X12 Release 5010 Revised May 24, 2023 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care 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 billing information, 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 to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and or payment of health care services within a specific health care insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such 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 a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care insurance industry segment. Delimiters Segment Element Component Repetition 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 1 579 View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional- x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX POWERED BY Build EDI implementation guides at stedi.com 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 2 579 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0050 Transaction Set Header Max use 1 Required BHT 0100 Beginning of Hierarchical Transaction Max use 1 Required Submitter Name Loop NM1 0200 Submitter Name Max use 1 Required PER 0450 Submitter EDI Contact Information Max use 2 Required Receiver Name Loop NM1 0200 Receiver Name Max use 1 Required Detail Billing Provider Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PRV 0030 Billing Provider Specialty Information Max use 1 Optional CUR 0100 Foreign Currency Information Max use 1 Optional Billing Provider Name Loop NM1 0150 Billing Provider Name Max use 1 Required N3 0250 Billing Provider Address Max use 1 Required N4 0300 Billing Provider City, State, ZIP Code Max use 1 Required REF 0350 Billing Provider Tax Identification Max use 1 Required PER 0400 Billing Provider Contact Information Max use 2 Optional Pay-to Address Name Loop NM1 0150 Pay-to Address Name Max use 1 Required N3 0250 Pay-to Address - ADDRESS Max use 1 Required N4 0300 Pay-To Address City, State, ZIP Code Max use 1 Required Pay-To Plan Name Loop 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 3 579 NM1 0150 Pay-To Plan Name Max use 1 Required N3 0250 Pay-to Plan Address Max use 1 Required N4 0300 Pay-To Plan City, State, ZIP Code Max use 1 Required REF 0350 Pay-to Plan Secondary Identification Max use 1 Optional REF 0350 Pay-To Plan Tax Identification Number Max use 1 Required Subscriber Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required SBR 0050 Subscriber Information Max use 1 Required Subscriber Name Loop NM1 0150 Subscriber Name Max use 1 Required N3 0250 Subscriber Address Max use 1 Optional N4 0300 Subscriber City, State, ZIP Code Max use 1 Optional DMG 0320 Subscriber Demographic Information Max use 1 Optional REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Subscriber Secondary Identification Max use 1 Optional Payer Name Loop NM1 0150 Payer Name Max use 1 Required N3 0250 Payer Address Max use 1 Optional N4 0300 Payer City, State, ZIP Code Max use 1 Optional REF 0350 Billing Provider Secondary Identification Max use 1 Optional REF 0350 Payer Secondary Identification Max use 3 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Admission Date Hour Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional DTP 1350 Discharge Hour Max use 1 Optional DTP 1350 Statement Dates Max use 1 Required CL1 1400 Institutional Claim Code Max use 1 Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 4 579 PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Estimated Amount Due Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Auto Accident State Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 5 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Peer Review Organization (PRO) Approval Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Billing Note Max use 1 Optional NTE 1900 Claim Note Max use 10 Optional CRC 2200 EPSDT Referral Max use 1 Optional HI 2310 Admitting Diagnosis Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Diagnosis Related Group (DRG) Information Max use 1 Optional HI 2310 External Cause of Injury Max use 1 Optional HI 2310 Occurrence Information Max use 2 Optional HI 2310 Occurrence Span Information Max use 2 Optional HI 2310 Other Diagnosis Information Max use 2 Optional HI 2310 Other Procedure Information Max use 2 Optional HI 2310 Patient's Reason For Visit Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 5 579 HI 2310 Principal Diagnosis Max use 1 Required HI 2310 Principal Procedure Information Max use 1 Optional HI 2310 Treatment Code Information Max use 2 Optional HI 2310 Value Information Max use 2 Optional HCP 2410 Claim Pricing Repricing Information Max use 1 Optional Attending Provider Name Loop NM1 2500 Attending Provider Name Max use 1 Required PRV 2550 Attending Provider Specialty Information Max use 1 Optional REF 2710 Attending Provider Secondary Identification Max use 4 Optional Operating Physician Name Loop NM1 2500 Operating Physician Name Max use 1 Required REF 2710 Operating Physician Secondary Identification Max use 4 Optional Other Operating Physician Name Loop NM1 2500 Other Operating Physician Name Max use 1 Required REF 2710 Other Operating Physician Secondary Identification Max use 4 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Other Subscriber Information Loop 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 6 579 SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MIA 3150 Inpatient Adjudication Information Max use 1 Optional MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 2 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3500 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Attending Provider Loop NM1 3250 Other Payer Attending Provider Max use 1 Required REF 3550 Other Payer Attending Provider Secondary Identification Max use 4 Required Other Payer Operating Physician Loop 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 7 579 NM1 3250 Other Payer Operating Physician Max use 1 Required REF 3550 Other Payer Operating Physician Secondary Identification Max use 4 Required Other Payer Other Operating Physician Loop NM1 3250 Other Payer Other Operating Physician Max use 1 Required REF 3550 Other Payer Other Operating Physician Secondary Identification Max use 4 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Rendering Provider Name Loop NM1 3250 Other Payer Rendering Provider Name Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 4 Required Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV2 3750 Institutional Service Line Max use 1 Required PWK 4200 Line Supplemental Information Max use 10 Optional DTP 4550 Date - Service Date Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 8 579 AMT 4750 Facility Tax Amount Max use 1 Optional AMT 4750 Service Tax Amount Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional HCP 4920 Line Pricing Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Operating Physician Name Loop NM1 5000 Operating Physician Name Max use 1 Required REF 5250 Operating Physician Secondary Identification Max use 20 Optional Other Operating Physician Name Loop NM1 5000 Other Operating Physician Name Max use 1 Required REF 5250 Other Operating Physician Secondary Identification Max use 20 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional Patient Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 9 579 PAT 0070 Patient Information Max use 1 Required Patient Name Loop NM1 0150 Patient Name Max use 1 Required N3 0250 Patient Address Max use 1 Required N4 0300 Patient City, State, ZIP Code Max use 1 Required DMG 0320 Patient Demographic Information Max use 1 Required REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Property and Casualty Patient Identifier Max use 1 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Admission Date Hour Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional DTP 1350 Discharge Hour Max use 1 Optional DTP 1350 Statement Dates Max use 1 Required CL1 1400 Institutional Claim Code Max use 1 Required PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Estimated Amount Due Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Auto Accident State Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 5 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Peer Review Organization (PRO) Approval Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 10 579 REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Billing Note Max use 1 Optional NTE 1900 Claim Note Max use 10 Optional CRC 2200 EPSDT Referral Max use 1 Optional HI 2310 Admitting Diagnosis Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Diagnosis Related Group (DRG) Information Max use 1 Optional HI 2310 External Cause of Injury Max use 1 Optional HI 2310 Occurrence Information Max use 2 Optional HI 2310 Occurrence Span Information Max use 2 Optional HI 2310 Other Diagnosis Information Max use 2 Optional HI 2310 Other Procedure Information Max use 2 Optional HI 2310 Patient's Reason For Visit Max use 1 Optional HI 2310 Principal Diagnosis Max use 1 Required HI 2310 Principal Procedure Information Max use 1 Optional HI 2310 Treatment Code Information Max use 2 Optional HI 2310 Value Information Max use 2 Optional HCP 2410 Claim Pricing Repricing Information Max use 1 Optional Attending Provider Name Loop NM1 2500 Attending Provider Name Max use 1 Required PRV 2550 Attending Provider Specialty Information Max use 1 Optional REF 2710 Attending Provider Secondary Identification Max use 4 Optional Operating Physician Name Loop NM1 2500 Operating Physician Name Max use 1 Required REF 2710 Operating Physician Secondary Identification Max use 4 Optional Other Operating Physician Name Loop NM1 2500 Other Operating Physician Name Max use 1 Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 11 579 REF 2710 Other Operating Physician Secondary Identification Max use 4 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MIA 3150 Inpatient Adjudication Information Max use 1 Optional MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 2 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 12 579 Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3500 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Attending Provider Loop NM1 3250 Other Payer Attending Provider Max use 1 Required REF 3550 Other Payer Attending Provider Secondary Identification Max use 4 Required Other Payer Operating Physician Loop NM1 3250 Other Payer Operating Physician Max use 1 Required REF 3550 Other Payer Operating Physician Secondary Identification Max use 4 Required Other Payer Other Operating Physician Loop NM1 3250 Other Payer Other Operating Physician Max use 1 Required REF 3550 Other Payer Other Operating Physician Secondary Identification Max use 4 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Rendering Provider Name Loop NM1 3250 Other Payer Rendering Provider Name Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 4 Required Other Payer Referring Provider Loop 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 13 579 NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV2 3750 Institutional Service Line Max use 1 Required PWK 4200 Line Supplemental Information Max use 10 Optional DTP 4550 Date - Service Date Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Facility Tax Amount Max use 1 Optional AMT 4750 Service Tax Amount Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional HCP 4920 Line Pricing Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Operating Physician Name Loop NM1 5000 Operating Physician Name Max use 1 Required REF 5250 Operating Physician Secondary Identification Max use 20 Optional Other Operating Physician Name Loop NM1 5000 Other Operating Physician Name Max use 1 Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 14 579 REF 5250 Other Operating Physician Secondary Identification Max use 20 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 15 579 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250131 2345 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 16 579 Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 17 579 Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 18 579 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HC XXXXXXX XXXX 20250131 0038 00000000 X 00501 0X223A3 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HC Health Care Claim (837) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 19 579 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X223A3 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 20 579 Heading ST 0050 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 837 0001 005010X223A3 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). 837 Health Care Claim ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. ST-03 1705 Version, Release, or Industry Identifier String (AN) Required Reference assigned to identify Implementation Convention The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08. Usage notes This element must be populated with the guide identifier named in Section 1.2. This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time. 005010X223A3 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 21 579 BHT 0100 Heading BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT 0019 00 XXXX 20250131 0823 RP Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. BHT-03 127 Originator Application Transaction Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 22 579 year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time Time (TM) Required HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim Identifier Identifier (ID) Required Code specifying the type of transaction 31 Subrogation Demand The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners. NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction. CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. RP Reporting Use RP when the entire ST-SE envelope contains only capitated encounters. Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 23 579 1000A Submitter Name Loop Max 1 Required Variants (all may be used) Receiver Name Loop NM1 0200 Heading Submitter Name Loop NM1 Submitter Name To supply the full name of an individual or organizational entity Usage notes The submitter is the entity responsible for the creation and formatting of this transaction. Example NM1 41 2 EMDEON XXXXX XX 46 133052274 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 41 Submitter NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Submitter Last or Organization Name String (AN) Required Individual last name or organizational name EMDEON NM1-04 1036 Submitter First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Submitter Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-08 66 Identification Code Qualifier Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 24 579 Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) Established by trading partner agreement NM1-09 67 Submitter Identifier String (AN) Required Code identifying a party or other code 133052274 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 25 579 PER 0450 Heading Submitter Name Loop PER Submitter EDI Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER IC EMDEON CUSTOMER SOLUTIONS TE 8008456592 E M XXXXX EM XXXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Submitter Contact Name String (AN) Optional Free-form name EMDEON CUSTOMER SOLUTIONS PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 26 579 1000A Submitter Name Loop end Complete communications number including country or area code when applicable 8008456592 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 27 579 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop NM1 0200 Heading Receiver Name Loop NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1 40 2 XX 46 801420001 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 40 Receiver NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Receiver Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier String (AN) Required Code identifying a party or other code 801420001 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 28 579 1000B Receiver Name Loop end Heading end 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 29 579 Detail 2000A Billing Provider Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 1 20 1 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 30 579 PRV 0030 Detail Billing Provider Hierarchical Level Loop PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRV BI PXC XX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 31 579 CUR 0100 Detail Billing Provider Hierarchical Level Loop CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send. It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars. Example CUR 85 XXX Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD Canadian dollars would be valid, while CA Canada would be invalid. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 32 579 2010AA Billing Provider Name Loop Max 1 Required Variants (all may be used) Pay-to Address Name Loop Pay-To Plan Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop NM1 Billing Provider Name To supply the full name of an individual or organizational entity Usage notes Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID- 2010BB. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop. When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. Example NM1 85 2 X XX XXXX If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 33 579 2 Non-Person Entity NM1-03 1035 Billing Provider Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Billing Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 34 579 N3 0250 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N3 Billing Provider Address To specify the location of the named party Usage notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3 XX XXXXX Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 35 579 N4 0300 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Usage notes Include city, 2-character state code and 9-digit ZIP code. Example N4 XXXXXX XX XXXXXXXX XX Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Billing Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Billing Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Billing Provider Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 36 579 Usage notes Use the country subdivision | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_0 |
579 2 Non-Person Entity NM1-03 1035 Billing Provider Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Billing Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 34 579 N3 0250 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N3 Billing Provider Address To specify the location of the named party Usage notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3 XX XXXXX Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 35 579 N4 0300 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Usage notes Include city, 2-character state code and 9-digit ZIP code. Example N4 XXXXXX XX XXXXXXXX XX Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Billing Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Billing Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Billing Provider Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 36 579 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 37 579 REF 0350 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop REF Billing Provider Tax Identification To specify identifying information Usage notes This is the tax identification number (TIN) of the entity to be paid for the submitted services. Example REF EI XX Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Billing Provider Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 38 579 PER 0400 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.; When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER IC XXXX TE XX EM XXX TE XXXXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Billing Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 39 579 2010AA Billing Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 40 579 2010AB Pay-to Address Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-To Plan Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information. Example NM1 87 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 87 Pay-to Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 41 579 N3 0250 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop N3 Pay-to Address - ADDRESS To specify the location of the named party Example N3 X XXXX Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 42 579 N4 0300 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop N4 Pay-To Address City, State, ZIP Code To specify the geographic place of the named party Usage notes Include city, 2-character state code and 9-digit ZIP code. Example N4 XXXXXXX XX XXXXXXX XX Only one of Pay-to Address State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-to Address City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-to Address State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-to Address Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 43 579 2010AB Pay-to Address Name Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 44 579 2010AC Pay-To Plan Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-to Address Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop NM1 Pay-To Plan Name To supply the full name of an individual or organizational entity Usage notes Required when willing trading partners agree to use this implementation for their subrogation payment requests. This loop may only be used when BHT06 31. Example NM1 PE 2 XXXX PI XXXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee PE is used to indicate the subrogated payee. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Pay-To Plan Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 45 579 Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Pay-To Plan Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 46 579 N3 0250 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop N3 Pay-to Plan Address To specify the location of the named party Example N3 XXXXX XXXXXX Max use 1 Required N3-01 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 47 579 N4 0300 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop N4 Pay-To Plan City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXXX XX Only one of Pay-To Plan State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-To Plan City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-To Plan State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-To Plan Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 48 579 REF 0350 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop REF Pay-to Plan Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF FY XXXXX Variants (all may be used) REF Pay-To Plan Tax Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Pay-to Plan Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 49 579 2010AC Pay-To Plan Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop REF Pay-To Plan Tax Identification Number To specify identifying information Example REF EI XXXXX Variants (all may be used) REF Pay-to Plan Secondary Identification Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Pay-To Plan Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 50 579 2000B Subscriber Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 2 1 22 1 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 22 Subscriber HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 51 579 0 No Subordinate HL Segment in This Hierarchical Structure. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 52 579 SBR 0050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBR C 18 X XXXXXX OF Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. 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 This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 53 579 This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 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) Medicare Risk 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 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 54 579 2010BA Subscriber Name Loop Max 1 Required Variants (all may be used) Payer Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes 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. Example NM1 IL 2 XXXXX XXXXXX XXXXX XXXXXX II XXX If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 55 579 Individual middle name or initial NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 56 579 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3 XXX XXXX Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Subscriber Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 57 579 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop N4 Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4 XXX XX XXXXX XX Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Subscriber State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 58 579 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 59 579 DMG 0320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop DMG Subscriber Demographic Information To supply demographic information Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example DMG D8 XXX M Max use 1 Optional DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Subscriber Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Subscriber Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 60 579 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop REF Property and Casualty Claim Number To specify identifying information Usage notes This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. Example REF Y4 XXXX Variants (all may be used) REF Subscriber Secondary Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 61 579 2010BA Subscriber Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop REF Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY XXXXXX Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Subscriber Supplemental Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 62 579 2010BB Payer Name Loop Max 1 Required Variants (all may be used) Subscriber Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop NM1 Payer Name To supply the full name of an individual or organizational entity Usage notes This is the destination payer. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator. Example NM1 PR 2 XXX XV XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 63 579 Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Payer Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 64 579 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N3 Payer Address To specify the location of the named party Usage notes 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. Example N3 XXXXXX XXXXXX Max use 1 Optional N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 65 579 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XXX XX XXX XXX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 66 579 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 67 579 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop REF Billing Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU XXXX Variants (all may be used) REF Payer Secondary Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Billing Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 68 579 2010BB Payer Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop REF Payer Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF NF XXXXX Variants (all may be used) REF Billing Provider Secondary Identification Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Payer Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 69 579 2300 Claim Information Loop Max 100 Optional CLM 1300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. 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 hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLM XXXXX 00000000000000 X A X B N I 8 Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is 20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 70 579 CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim. CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. A Uniform Billing Claim Form Bill Type C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 71 579 B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 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 Reason Unrelated to the Billing Limitation Rules 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 72 579 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 73 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Admission Date Hour To specify any or all of a date, a time, or a time period Usage notes Required on inpatient claims. If not required by this implementation guide, do not send. Example DTP 435 DT X Variants (all may be used) DTP Date - Repricer Received Date DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes Selection of the appropriate qualifier is designated by the NUBC Billing Manual. D8 Date Expressed in Format CCYYMMDD DT Date and Time Expressed in Format CCYYMMDDHHMM DTP-03 1251 Admission Date and Hour Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 74 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP 050 D8 XXX Variants (all may be used) DTP Admission Date Hour DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 75 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Discharge Hour To specify any or all of a date, a time, or a time period Usage notes Required on all final inpatient claims. If not required by this implementation guide, do not send. Example DTP 096 TM XXXXXX Variants (all may be used) DTP Admission Date Hour DTP Date - Repricer Received Date DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. TM Time Expressed in Format HHMM DTP-03 1251 Discharge Time Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 76 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_1 |
format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes Selection of the appropriate qualifier is designated by the NUBC Billing Manual. D8 Date Expressed in Format CCYYMMDD DT Date and Time Expressed in Format CCYYMMDDHHMM DTP-03 1251 Admission Date and Hour Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 74 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP 050 D8 XXX Variants (all may be used) DTP Admission Date Hour DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 75 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Discharge Hour To specify any or all of a date, a time, or a time period Usage notes Required on all final inpatient claims. If not required by this implementation guide, do not send. Example DTP 096 TM XXXXXX Variants (all may be used) DTP Admission Date Hour DTP Date - Repricer Received Date DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. TM Time Expressed in Format HHMM DTP-03 1251 Discharge Time Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 76 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Statement Dates To specify any or all of a date, a time, or a time period Example DTP 434 RD8 X Variants (all may be used) DTP Admission Date Hour DTP Date - Repricer Received Date DTP Discharge Hour Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 434 Statement DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same. DTP-03 1251 Statement From and To Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 77 579 CL1 1400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CL1 Institutional Claim Code To supply information specific to hospital claims Example CL1 X X XX Max use 1 Required CL1-01 1315 Admission Type Code Min 1 Max 1 Identifier (ID) Required Code indicating the priority of this admission CL1-02 1314 Admission Source Code Min 1 Max 1 Identifier (ID) Optional Code indicating the source of this admission CL1-03 1352 Patient Status Code Min 1 Max 2 Identifier (ID) Required Code indicating patient status as of the "statement covers through date" 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 78 579 PWK 1550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK A4 FT AC XXXXXX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 79 579 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 80 579 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 81 579 CN1 1600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CN1 Contract Information To specify basic data about the contract or contract line item Usage notes Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet 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. Example CN1 03 0000000000 0 XXXXXX 00000 X Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 82 579 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 83 579 AMT 1750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop AMT Patient Estimated Amount Due To indicate the total monetary amount Usage notes Required when the Patient Responsibility Amount is applicable to this claim. If not required by this implementation guide, do not send. Example AMT F3 000000000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F3 Patient Responsibility - Estimated AMT-02 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 84 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF 9C X Variants (all may be used) REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 85 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Auto Accident State To specify identifying information Usage notes Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub- country code named in code source 22. If not required by this implementation guide, do not send. Example REF LU XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LU Location Number REF-02 127 Auto Accident State or Province Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Values in this field must be valid codes found in code source 22. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 86 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REF D9 XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 87 579 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 88 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF P4 XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 89 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REF LX XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 90 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REF EA XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 91 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF F8 XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 92 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Peer Review Organization (PRO) Approval Number To specify identifying information Usage notes Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send. Example REF G4 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G4 Peer Review Organization (PRO) Approval Number REF-02 127 Peer Review Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 93 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF G1 XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 94 579 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 95 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF 9F XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 96 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Repriced Claim Number To specify identifying information Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example REF 9A XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 97 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF 4N X Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Allowable values for this element are: 1 Immediate Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 98 579 6 Request for Override Pending 7 Special Handling 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 99 579 K3 1850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop K3 File Information To transmit a fixed-format record or matrix contents Usage notes 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. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3 XXXXXX Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 100 579 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop NTE Billing Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Example NTE ADD XX Variants (all may be used) NTE Claim Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information NTE-02 352 Billing Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 101 579 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. OR Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services. If not required by this implementation guide, do not send. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTE RLH XXXXX Variants (all may be used) NTE Billing Note Max use 10 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ALG Allergies DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description DME Durable Medical Equipment (DME) and Supplies 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 Information NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 102 579 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC EPSDT Referral To supply information on conditions Usage notes Required on Early Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRC ZZ Y AV XX XX Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 103 579 ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 104 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Admitting Diagnosis To supply information related to the delivery of health care Usage notes Required when claim involves an inpatient admission. If not required by this implementation guide, do not send.; Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BJ XXX Variants (all may be used) HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABJ International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BJ International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis C022-02 1271 Admitting Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 105 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 106 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Condition Information To supply information related to the delivery of health care Usage notes Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BG X BG XXX BG XX BG X BG X BG XXXXXX BG XXXX X BG X BG XXXXXX BG XXX BG XXXX BG XXX Variants (all may be used) HI Admitting Diagnosis HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 107 579 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 108 579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 109 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 110 579 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 111 579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 112 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Diagnosis Related Group (DRG) | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_2 |
codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 111 579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 112 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Diagnosis Related Group (DRG) Information To supply information related to the delivery of health care Usage notes Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send. Example HI DR XX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. DR Diagnosis Related Group (DRG) C022-02 1271 Diagnosis Related Group (DRG) Code String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 113 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI External Cause of Injury To supply information related to the delivery of health care Usage notes 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. Do not transmit the decimal point for ICD codes. The decimal point is implied. In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes. Example HI BN XXXXX W ABN XXXXXX N BN XXX Y BN XXXX W ABN XXXXXX N BN XXXX N BN XXXXX Y BN XXXX W ABN XX U BN XXX Y ABN XXX W ABN XX Y Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 114 579 the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 115 579 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 116 579 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 117 579 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 118 579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 119 579 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 120 579 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 121 579 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 122 579 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 123 579 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 124 579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 125 579 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 126 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Occurrence Information To supply information related to the delivery of health care Usage notes Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BH XXXXX D8 XXX BH XXXXXX D8 XXXXXX BH XXXX D 8 XXXXX BH XX D8 XXXX BH XXX D8 XXXXX BH XXX D8 X XXXXX BH XX D8 XXX BH XXXXXX D8 XXXX BH X D8 XX X BH XX D8 XXXXX BH XX D8 XXXXX BH XXXXXX D8 XXXX XX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 127 579 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 128 579 Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 129 579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 130 579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 131 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 132 579 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 133 579 BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 134 579 C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 135 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Occurrence Span Information To supply information related to the delivery of health care Usage notes Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BI XXXXXX RD8 XX BI XXXXXX RD8 XX BI XXXXX RD 8 XXXX BI XXX RD8 XXXXXX BI XXXXXX RD8 XXXX BI X X RD8 XXX BI XXXXX RD8 XXXXX BI XXXX RD8 XXXX B I XXXXX RD8 XXXXXX BI XX RD8 X BI XXXX RD8 XXXX B I XXXXXX RD8 XXXXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 136 579 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_3 |
their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 135 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Occurrence Span Information To supply information related to the delivery of health care Usage notes Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BI XXXXXX RD8 XX BI XXXXXX RD8 XX BI XXXXX RD 8 XXXX BI XXX RD8 XXXXXX BI XXXXXX RD8 XXXX BI X X RD8 XXX BI XXXXX RD8 XXXXX BI XXXX RD8 XXXX B I XXXXX RD8 XXXXXX BI XX RD8 X BI XXXX RD8 XXXX B I XXXXXX RD8 XXXXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 136 579 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 137 579 Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 138 579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 139 579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 140 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 141 579 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 142 579 BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 143 579 C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 144 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Other Diagnosis Information To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. If not required by this implementation guide, do not send. Example HI BF XXXX W ABF XXX N BF XXXXXX N BF XXXXXX Y BF XXXX U BF XXXXX W BF XX U BF XXXXX N ABF XXXX U ABF XXXXXX W BF XX W ABF XXX N Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 145 579 BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 146 579 C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 147 579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 148 579 Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 149 579 an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 150 579 C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 151 579 N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 152 579 Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 153 579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 154 579 Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 155 579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 156 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Other Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BQ XXXX D8 XXX BQ XXXXXX D8 XXXX BBQ XXXXX D 8 XXXXX BQ XXXX D8 XXXXXX BQ XX D8 XXXX BBQ XXX D 8 XXX BQ XX D8 XXXXX BQ XX D8 XXXX BBQ XXXXXX D 8 XX BQ XXXXX D8 X BBQ XXXXX D8 XXXXXX BBQ X D8 X XXXXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 157 579 OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 158 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 159 579 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_4 |
this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 158 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 159 579 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 160 579 Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 161 579 Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 162 579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 163 579 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 164 579 C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 165 579 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 166 579 Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 167 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Patient's Reason For Visit To supply information related to the delivery of health care Usage notes Required when claim involves outpatient visits. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI PR XXXX PR XXX APR XXXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 168 579 APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 169 579 HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 170 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Principal Diagnosis To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BK XX N Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Principal Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 171 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 172 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Principal Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI CAH XXXXX D8 X Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 173 579 BBR International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BR International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes CAH Advanced Billing Concepts (ABC) Codes C022-02 1271 Principal Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Principal Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 174 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Treatment Code Information To supply information related to the delivery of health care Usage notes Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. If not required by this implementation guide, do not send. Example HI TC XXX TC XXX TC X TC XXXX TC XXXXXX TC XXX T C XXXXX TC XXXXX TC X TC XXXXXX TC XX TC XXXXXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 175 579 Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 176 579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 177 579 TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 178 579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 179 579 Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 180 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Value Information To supply information related to the delivery of health care Usage notes Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BE XXX 000000000 BE XXX 0 BE XXXXXX 0 B E XXX 0000 BE X 0000000000 BE XX 000 BE XXX X 00000000000000 BE XXXXX 000000000000 BE XXX XX 0000000 BE XXX 0000000000000 BE XXX 0000 0000 BE XXXX 00000000 Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 181 579 C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 182 579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 183 579 C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 184 579 BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 185 579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_5 |
specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 184 579 BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 185 579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 186 579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 187 579 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 188 579 HCP 2410 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HCP Claim Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 04 0000000000 00000 XXXXXX 000 XXXXX 00 XXXX X DA 000 T4 4 3 If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 189 579 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved DRG Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 190 579 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Repriced Approved Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 191 579 This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 192 579 2310A Attending Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop NM1 Attending Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send. The Attending Provider is the individual who has overall responsibility for the patient's medical care and treatment reported in this claim. Example NM1 71 1 XXXX XXX XX X XX XXXXX If either Identification Code Qualifier (NM1-08) or Attending Provider Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 71 Attending Physician When used, the term physician is any type of provider filling this role. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Attending Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Attending Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 193 579 Individual first name NM1-05 1037 Attending Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Attending Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Attending Provider Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 194 579 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop PRV Attending Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send. Example PRV AT PXC XXXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AT Attending PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 195 579 2310A Attending Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop REF Attending Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF G2 XXXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Attending Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Health partners provider identification number (5 digits). 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 196 579 2310B Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Operating Physician Name Loop NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 72 1 X X XX XXXXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 197 579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 198 579 2310B Operating Physician Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Operating Physician Name Loop REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF G2 XXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 199 579 2310C Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Operating Physician Name Loop NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved. If not required by the implementation guide, do not send. The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician. This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 ZZ 1 X XXXXX XXX XXXXX XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 200 579 Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 201 579 2310C Other Operating Physician Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Operating Physician Name Loop REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 0B XXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 202 579 2310D Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 82 1 XX XXXX XXXXX XXXX XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 203 579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 204 579 2310D Rendering Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU XXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 205 579 2310E Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Example NM1 77 2 XXXXXX XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 206 579 Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 207 579 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXXXXX XXXXXX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 208 579 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Usage notes Include city, 2-character state code and 9-digit ZIP code. Example N4 XXXXXXX XX XXXXX XX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 209 579 Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 210 579 2310E Service Facility Location Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF LU XXXXX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 211 579 2310F Referring Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 DN 1 XXXXXX XXXXX XXX XXXXXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 212 579 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 213 579 2310F Referring Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Example REF G2 X Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 214 579 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR G 20 XXX XX MB Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. 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 This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 215 579 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 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) Medicare Risk 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 Use code OF when submitting Medicare Part D claims. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 216 579 TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 217 579 CAS 2950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS CR XXX 00000000 00 XX 000000000000000 000000 0 XXXX 000 00000000000 XXXXX 0 0000000000000 XX 0 0000000 00 XXXX 000000000000 000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 218 579 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 219 579 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 220 579 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 221 579 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_6 |
Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 219 579 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 220 579 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 221 579 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT D 0000000000 Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 222 579 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT A8 0000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 223 579 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 000000000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 224 579 OI 3100 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI W I Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 225 579 MIA 3150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes Required when inpatient adjudication information is reported in the remittance advice. OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MIA 0000 0000000 0000 X 000000000000 000000 0000 00 00 000 000000000 0 0 000 0000 0 000000 0000000 000 00000000 X XXXX XXX XXX 000000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 226 579 MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 227 579 MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 228 579 MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 229 579 MOA 3200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA 0 000 XX XXXXXX XXXX XX XXXX 000000000 000000 000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 230 579 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 231 579 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 IL 1 X XXXXX XXXXXX XXXXX II XXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 232 579 Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 233 579 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3 XXX XXXX Max use 1 Optional N3-01 166 Other Insured Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 234 579 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4 XXXXXX XX XXXXXXXX XX Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Insured City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Insured State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Insured Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 235 579 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 236 579 2330A Other Subscriber Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY XXXX Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 237 579 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 PR 2 XXXXXX PI XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 238 579 Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 239 579 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N3 Other Payer Address To specify the location of the named party Usage notes 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. Example N3 XXXXXX XXXX Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 240 579 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XX XX XXXX XX Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 241 579 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 242 579 DTP 3500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP 573 D8 XXXXX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 243 579 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REF T4 XXXXX Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Only allowed value is "Y". 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 244 579 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REF F8 XX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only. REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 245 579 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REF G1 X Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 246 579 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF 9F XXXXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 247 579 2330B Other Payer Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF 2U XX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 248 579 2330C Other Payer Attending Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Attending Provider Loop NM1 Other Payer Attending Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 71 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 71 Attending Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 249 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 250 579 2330C Other Payer Attending Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Attending Provider Loop REF Other Payer Attending Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF G2 XXXXX Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Attending Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 251 579 2330D Other Payer Operating Physician Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Operating Physician Loop NM1 Other Payer Operating Physician To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 72 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 252 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 253 579 2330D Other Payer Operating Physician Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Operating Physician Loop REF Other Payer Operating Physician Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF 0B XXXXX Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Operating Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 254 579 2330E Other Payer Other Operating Physician Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Other Operating Physician Loop NM1 Other Payer Other Operating Physician To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 ZZ 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 255 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 256 579 2330E Other Payer Other Operating Physician Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Other Operating Physician Loop REF Other Payer Other Operating Physician Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF 0B XXX Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Other Operating Physician Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 257 579 2330F Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 77 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 258 579 2 Non-Person Entity 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 259 579 2330F Other Payer Service Facility Location Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop REF Other Payer Service Facility Location Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF G2 XXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_7 |
health plan. LU Location Number REF-02 127 Other Payer Other Operating Physician Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 257 579 2330F Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 77 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 258 579 2 Non-Person Entity 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 259 579 2330F Other Payer Service Facility Location Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop REF Other Payer Service Facility Location Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF G2 XXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 260 579 2330G Other Payer Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Rendering Provider Name Loop NM1 Other Payer Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 82 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 261 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 262 579 2330G Other Payer Rendering Provider Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Rendering Provider Name Loop REF Other Payer Rendering Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU X Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Rendering Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 263 579 2330H Other Payer Referring Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Referring Provider Loop NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 DN 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 264 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 265 579 2330H Other Payer Referring Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Referring Provider Loop REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF 0B XX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 266 579 2330I Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Billing Provider Loop NM1 Other Payer Billing Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 85 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 267 579 2 Non-Person Entity 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 268 579 2330I Other Payer Billing Provider Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Billing Provider Loop REF Other Payer Billing Provider Secondary Identification To specify identifying information Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF G2 XXXXXX Max use 2 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Billing Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 269 579 2400 Service Line Number Loop Max 999 Required LX 3650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX 000 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 270 579 SV2 3750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV2 Institutional Service Line To specify the service line item detail for a health care institution Example SV2 XXXXX HP XX XX XX XX XX XX 000000000000 DA 0 000000000000 Max use 1 Required SV2-01 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SV201 is the revenue code. Usage notes See Code Source 132: National Uniform Billing Committee (NUBC) Codes. SV2-02 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Usage notes Required for outpatient claims when an appropriate procedure code exists for this service line item. OR Required for inpatient claims when an appropriate HCPCS (drugs and or biologics only) or HIPPS code exists for this service line item. If not required by this implementation guide, do not send.; Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product Service Code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 271 579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 272 579 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV2-03 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV203 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV2-04 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit SV2-05 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV2-07 782 Line Item Denied Charge or Non-Covered Charge Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 273 579 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK CK AA AC XXXXXXX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 274 579 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 275 579 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 276 579 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes Required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day. OR Required on service lines where a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written. If not required by this implementation guide, do not send. In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and 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 first day of the drug used by the patient is 1 1 00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was 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 supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1 1 00. In cases where a drug is being billed on a service line, a single date may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written). Example DTP 472 RD8 XXXXX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 277 579 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 278 579 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9D XXXX Variants (all may be used) REF Line Item Control Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 279 579 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF 6R XXXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 280 579 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9B XXXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Line Item Control Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 281 579 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Facility Tax Amount To indicate the total monetary amount Usage notes Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Facility Tax Amount. Example AMT N8 00000000 Variants (all may be used) AMT Service Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount N8 Miscellaneous Taxes AMT-02 782 Facility Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 282 579 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Service Tax Amount To indicate the total monetary amount Usage notes Required when a service tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Service Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Service Tax Amount. Example AMT GT 0 Variants (all may be used) AMT Facility Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount GT Goods and Services Tax AMT-02 782 Service Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 283 579 NTE 4850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTE TPO X Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 284 579 HCP 4920 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop HCP Line Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 09 00000000000 00000 XXXXX 00 XXXXXX 00000000 0000 XXXXX IV XXXX UN 0 T6 3 1 If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Quantity (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 Pricing HCP-02 782 Monetary Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 285 579 HCP02 is the allowed amount. HCP-03 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Rate Min 1 Max 9 Decimal number (R) Optional Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 286 579 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Product or Service ID Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type source of the descriptive number used in Product Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 287 579 Identifying number for a product or service HCP10 is the approved procedure code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 288 579 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 289 579 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop LIN Drug Identification To specify basic item identification data Usage notes Drugs and biologics reported in this segment are a further specification of service(s) described in the SV2 segment of this Service Line Loop ID-2400. Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. If not required by this implementation guide, do not send. Example LIN N4 XXX Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) LIN02 through LIN31 provide for fifteen different product service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. N4 National Drug Code in 5-4-2 Format LIN-03 234 National Drug Code Min 1 Max 48 String (AN) Required Identifying number for a product or service 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 290 579 CTP 4940 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop CTP Drug Quantity To specify pricing information Example CTP 0000000 ME Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 291 579 2410 Drug Identification Loop end REF 4950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop REF Prescription or Compound Drug Association Number To specify identifying information Usage notes In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REF XZ XXXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 292 579 2420A Operating Physician Name Loop Max 1 Optional Variants (all may be used) Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Operating Physician Name Loop NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. AND The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level). If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Example NM1 72 1 XX XXXX XXXX XX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 293 579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 294 579 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Operating Physician Name Loop REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_8 |
Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 292 579 2420A Operating Physician Name Loop Max 1 Optional Variants (all may be used) Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Operating Physician Name Loop NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. AND The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level). If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Example NM1 72 1 XX XXXX XXXX XX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 293 579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 294 579 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Operating Physician Name Loop REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF LU XXXXX 2U XXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 295 579 2420A Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 296 579 2420B Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Other Operating Physician Name Loop NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved, AND The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level). If not required by this implementation guide, do not send.; Example NM1 ZZ 1 X XXX XX XXXXXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 297 579 Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 298 579 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Other Operating Physician Name Loop REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF LU XXXXXX 2U XXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 299 579 2420B Other Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 300 579 2420C Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim. AND State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) AND The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Example NM1 82 1 XXXXX XX XXXX XXX XX XX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 301 579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 302 579 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXXXX 2U XXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 303 579 2420C Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 304 579 2420D Referring Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. AND The Referring Provider for this line is different than the Referring Provider reported in Loop ID 2310F (claim level). If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Example NM1 DN 1 XXXXXX XXX XXXXXX XXXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 305 579 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 306 579 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXXX 2U XX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 307 579 2420D Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 308 579 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD XX 0000 ER XXXXXX XX XX XX XX XXXXX XXXXXX 0 0 0000 Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Usage notes Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01). Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 309 579 If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 310 579 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-04 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SVD04 is the revenue code. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 311 579 SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 312 579 CAS 5450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS CO XX 00000000000000 00000000 XXXXX 0000000 0 00000000000000 XXXX 00000000000000 00000000 XXX X 0000000000 000000000000 XX 0000000 000000000000 000 XXXX 0000 000000000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 313 579 If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 314 579 CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 315 579 See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 316 579 DTP 5500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP 573 D8 XX Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 317 579 2430 Line Adjudication Information Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end AMT 5505 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 318 579 2000C Patient Hierarchical Level Loop Max 1 Optional HL 0010 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 3 2 23 0 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 23 Dependent HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 319 579 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 320 579 PAT 0070 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop PAT Patient Information To supply patient information Example PAT 19 Max use 1 Required PAT-01 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities Usage notes Specifies the patient's relationship to the person insured. 01 Spouse 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 321 579 2010CA Patient Name Loop Max 1 Required NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop NM1 Patient Name To supply the full name of an individual or organizational entity Example NM1 QC 1 XXX XX XXXXX XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 322 579 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop N3 Patient Address To specify the location of the named party Example N3 XXXXXX XXXX Max use 1 Required N3-01 166 Patient Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Patient Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 323 579 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop N4 Patient City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXXX XX XXX XX Only one of Patient State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Patient City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Patient State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Patient Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 324 579 DMG 0320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop DMG Patient Demographic Information To supply demographic information Example DMG D8 XXXX U Max use 1 Required DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Patient Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Patient Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 325 579 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop REF Property and Casualty Claim Number To specify identifying information Usage notes This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. Example REF Y4 XXXXXX Variants (all may be used) REF Property and Casualty Patient Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 326 579 2010CA Patient Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop REF Property and Casualty Patient Identifier To specify identifying information Usage notes Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send. Example REF SY XX Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1W Member Identification Number This code designates a patient identification number used by the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Property and Casualty Patient Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 327 579 2300 Claim Information Loop Max 100 Required CLM 1300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. 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 hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLM XXXX 000 XX A X A Y Y 7 Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is 20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 328 579 Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim. CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. A Uniform Billing Claim Form Bill Type C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_9 |
to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is 20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 328 579 Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim. CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. A Uniform Billing Claim Form Bill Type C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 329 579 Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 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 Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 330 579 15 Natural Disaster 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 331 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Admission Date Hour To specify any or all of a date, a time, or a time period Usage notes Required on inpatient claims. If not required by this implementation guide, do not send. Example DTP 435 DT X Variants (all may be used) DTP Date - Repricer Received Date DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes Selection of the appropriate qualifier is designated by the NUBC Billing Manual. D8 Date Expressed in Format CCYYMMDD DT Date and Time Expressed in Format CCYYMMDDHHMM DTP-03 1251 Admission Date and Hour Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 332 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP 050 D8 XXX Variants (all may be used) DTP Admission Date Hour DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 333 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Discharge Hour To specify any or all of a date, a time, or a time period Usage notes Required on all final inpatient claims. If not required by this implementation guide, do not send. Example DTP 096 TM XXXX Variants (all may be used) DTP Admission Date Hour DTP Date - Repricer Received Date DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. TM Time Expressed in Format HHMM DTP-03 1251 Discharge Time Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 334 579 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Statement Dates To specify any or all of a date, a time, or a time period Example DTP 434 RD8 XXX Variants (all may be used) DTP Admission Date Hour DTP Date - Repricer Received Date DTP Discharge Hour Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 434 Statement DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same. DTP-03 1251 Statement From and To Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 335 579 CL1 1400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CL1 Institutional Claim Code To supply information specific to hospital claims Example CL1 X X XX Max use 1 Required CL1-01 1315 Admission Type Code Min 1 Max 1 Identifier (ID) Required Code indicating the priority of this admission CL1-02 1314 Admission Source Code Min 1 Max 1 Identifier (ID) Optional Code indicating the source of this admission CL1-03 1352 Patient Status Code Min 1 Max 2 Identifier (ID) Required Code indicating patient status as of the "statement covers through date" 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 336 579 PWK 1550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK RT AA AC XXXXXXX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 337 579 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 338 579 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 339 579 CN1 1600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CN1 Contract Information To specify basic data about the contract or contract line item Usage notes Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet 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. Example CN1 02 0000 000000 X 0 XXXXXX Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 340 579 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 341 579 AMT 1750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop AMT Patient Estimated Amount Due To indicate the total monetary amount Usage notes Required when the Patient Responsibility Amount is applicable to this claim. If not required by this implementation guide, do not send. Example AMT F3 000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F3 Patient Responsibility - Estimated AMT-02 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 342 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF 9C XXX Variants (all may be used) REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 343 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Auto Accident State To specify identifying information Usage notes Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub- country code named in code source 22. If not required by this implementation guide, do not send. Example REF LU X Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LU Location Number REF-02 127 Auto Accident State or Province Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Values in this field must be valid codes found in code source 22. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 344 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REF D9 XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 345 579 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 346 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF P4 XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 347 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REF LX XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 348 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REF EA XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 349 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF F8 XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 350 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Peer Review Organization (PRO) Approval Number To specify identifying information Usage notes Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send. Example REF G4 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G4 Peer Review Organization (PRO) Approval Number REF-02 127 Peer Review Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 351 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF G1 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 352 579 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 353 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF 9F X Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 354 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Repriced Claim Number To specify identifying information Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example REF 9A XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 355 579 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF 4N XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Allowable values for this element are: 1 Immediate Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 356 579 6 Request for Override Pending 7 Special Handling 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 357 579 K3 1850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop K3 File Information To transmit a fixed-format record or matrix contents Usage notes 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. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3 XX Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 358 579 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop NTE Billing Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Example NTE ADD XXXX Variants (all may be used) NTE Claim Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information NTE-02 352 Billing Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 359 579 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. OR Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services. If not required by this implementation guide, do not send. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTE SPT XXXX Variants (all may be used) NTE Billing Note Max use 10 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ALG Allergies DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description DME Durable Medical Equipment (DME) and Supplies 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 Information NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 360 579 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CRC EPSDT Referral To supply information on conditions Usage notes Required on Early Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRC ZZ N S2 XXX XX Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 361 579 ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 362 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Admitting Diagnosis To supply information related to the delivery of health care Usage notes Required when claim involves an inpatient admission. If not required by this implementation guide, do not send.; Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BJ X Variants (all may be used) HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABJ International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BJ International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis C022-02 1271 Admitting Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 363 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 364 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Condition Information To supply information related to the delivery of health care Usage notes Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BG X BG XXXXXX BG XXXX BG X BG XXX BG XXXX B G XXXX BG XXX BG XXXX BG XXXX BG X BG XXXXX Variants (all may be used) HI Admitting Diagnosis HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 365 579 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 366 579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_10 |
Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 365 579 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 366 579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 367 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 368 579 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 369 579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 370 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Diagnosis Related Group (DRG) Information To supply information related to the delivery of health care Usage notes Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send. Example HI DR X Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. DR Diagnosis Related Group (DRG) C022-02 1271 Diagnosis Related Group (DRG) Code String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 371 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI External Cause of Injury To supply information related to the delivery of health care Usage notes 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. Do not transmit the decimal point for ICD codes. The decimal point is implied. In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes. Example HI ABN X N BN XXX Y BN XXXX N B N XX U ABN XX N ABN XXX Y ABN X X Y ABN X Y ABN XXXX N BN XX Y ABN XXX N BN XXX U Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 372 579 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 373 579 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 374 579 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 375 579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 376 579 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 377 579 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 378 579 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 379 579 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 380 579 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 381 579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 382 579 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 383 579 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 384 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Occurrence Information To supply information related to the delivery of health care Usage notes Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BH XXX D8 XXXX BH XX D8 X BH X D8 XXX BH XXX X D8 XX BH XXXXX D8 XXXXXX BH XXXX D8 XXX BH XXXX XX D8 XX BH XXXX D8 XX BH XX D8 XXXX BH XXXXXX D 8 XXXXX BH X D8 XXXXXX BH XX D8 XXXXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 385 579 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 386 579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 387 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 388 579 Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 389 579 BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 390 579 C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_11 |
represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 389 579 BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 390 579 C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 391 579 C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 392 579 D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 393 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Occurrence Span Information To supply information related to the delivery of health care Usage notes Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BI XXXX RD8 XXXX BI XXXXXX RD8 X BI X RD8 XXXX X BI XXXXX RD8 XXX BI XXX RD8 XX BI XXX RD8 XXX B I XXXXX RD8 XXX BI XXXXXX RD8 XXXXXX BI XXXX RD 8 XX BI XXXXXX RD8 X BI XX RD8 XXXXX BI XXXXXX RD 8 X Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 394 579 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 395 579 Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 396 579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 397 579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 398 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 399 579 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 400 579 BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 401 579 C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 402 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Other Diagnosis Information To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. If not required by this implementation guide, do not send. Example HI BF XX Y ABF X Y ABF XXXXXX W ABF XXXXXX U BF XX N ABF XXXXXX N ABF XXXXX W BF XXXXX N BF X W ABF XX N BF XX N BF XXXX N Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 403 579 BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 404 579 C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 405 579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 406 579 Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 407 579 an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 408 579 C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 409 579 N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 410 579 Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 411 579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 412 579 Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 413 579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_12 |
to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 413 579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 414 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Other Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BBQ XXXXXX D8 XX BBQ XXX D8 XX BBQ XXXXXX D 8 X BBQ XXXXXX D8 XXXXXX BQ XXX D8 XXXXX BQ XXXX X D8 XXXXX BBQ X D8 XXXXX BBQ XX D8 XXXXX BQ X D 8 XX BBQ XX D8 XXXXXX BQ XX D8 X BBQ XX D8 XX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 415 579 BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 416 579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 417 579 D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 418 579 Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 419 579 Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 420 579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 421 579 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 422 579 C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 423 579 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 424 579 Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 425 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Patient's Reason For Visit To supply information related to the delivery of health care Usage notes Required when claim involves outpatient visits. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI PR X PR XXX APR XXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 426 579 APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 427 579 HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 428 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Principal Diagnosis To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BK X N Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Principal Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 429 579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 430 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Principal Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI CAH XXXXXX D8 XXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 431 579 BBR International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BR International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes CAH Advanced Billing Concepts (ABC) Codes C022-02 1271 Principal Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Principal Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 432 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Treatment Code Information To supply information related to the delivery of health care Usage notes Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. If not required by this implementation guide, do not send. Example HI TC XXX TC X TC XXXXXX TC XXXXXX TC X TC XXXX T C X TC XXX TC XXXX TC XXXXX TC XXX TC XXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 433 579 Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 434 579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 435 579 TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 436 579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 437 579 Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 438 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Value Information To supply information related to the delivery of health care Usage notes Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BE XXXX 000000000000000 BE XXXXX 000000 B E XXX 000 BE XXXX 00000 BE XXXXXX 00000 B E XXXX 000000000000000 BE XX 00000000000000 B E XXXXX 0000000000 BE XX 0 BE XXXX 00000000 000000 BE XX 000000000000 BE X 0000000000 Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 439 579 C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_13 |
C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 438 579 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Value Information To supply information related to the delivery of health care Usage notes Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BE XXXX 000000000000000 BE XXXXX 000000 B E XXX 000 BE XXXX 00000 BE XXXXXX 00000 B E XXXX 000000000000000 BE XX 00000000000000 B E XXXXX 0000000000 BE XX 0 BE XXXX 00000000 000000 BE XX 000000000000 BE X 0000000000 Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 439 579 C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 440 579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 441 579 C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 442 579 BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 443 579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 444 579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 445 579 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 446 579 HCP 2410 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HCP Claim Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 07 000000000 000 XXX 0000 XXXXXX 000000 XXXXX X DA 000000000000 T4 3 2 If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 447 579 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved DRG Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 448 579 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Repriced Approved Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 449 579 This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 450 579 2310A Attending Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop NM1 Attending Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send. The Attending Provider is the individual who has overall responsibility for the patient's medical care and treatment reported in this claim. Example NM1 71 1 XX X XXX XX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Attending Provider Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 71 Attending Physician When used, the term physician is any type of provider filling this role. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Attending Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Attending Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 451 579 Individual first name NM1-05 1037 Attending Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Attending Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Attending Provider Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 452 579 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop PRV Attending Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send. Example PRV AT PXC XXXXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AT Attending PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 453 579 2310A Attending Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop REF Attending Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU X Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Attending Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 454 579 2310B Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Operating Physician Name Loop NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 72 1 XX XXXXXX XXXX X XX XXXXXX If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 455 579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 456 579 2310B Operating Physician Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Operating Physician Name Loop REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU XXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 457 579 2310C Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Operating Physician Name Loop NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved. If not required by the implementation guide, do not send. The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician. This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 ZZ 1 XXXX XXXX X XXXXXX XX XXX If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 458 579 Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 459 579 2310C Other Operating Physician Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Operating Physician Name Loop REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 0B X Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 460 579 2310D Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 82 1 XXX XX XXXXXX XX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 461 579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 462 579 2310D Rendering Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 1G XXXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 463 579 2310E Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Example NM1 77 2 XX XX XXX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 464 579 Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 465 579 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 X XXXXXX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 466 579 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XX XX XXX XX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 467 579 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 468 579 2310E Service Facility Location Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF LU XX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 469 579 2310F Referring Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 DN 1 XXXXXX XXX X X XX XX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 470 579 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 471 579 2310F Referring Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Example REF G2 XXXXXX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 472 579 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR A 18 XX X 16 Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. 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 This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 473 579 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 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) Medicare Risk 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 Use code OF when submitting Medicare Part D claims. 1 30 25, 11:52 AM Health Partner Plans 837 Health | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_14 |
Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR A 18 XX X 16 Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. 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 This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 473 579 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 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) Medicare Risk 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 Use code OF when submitting Medicare Part D claims. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 474 579 TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 475 579 CAS 2950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS PR X 0000000000000 00000000000000 X 0000000 0 00000000000 XXX 00000000000000 0000000 XXXXX 000 0 00000000 XXXX 0000 0000 X 00000000000000 000000 00 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 476 579 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 477 579 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 478 579 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 479 579 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT D 000 Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 480 579 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT A8 00000000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 481 579 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 482 579 OI 3100 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI N Y Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 483 579 MIA 3150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes Required when inpatient adjudication information is reported in the remittance advice. OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MIA 000 00000000 00 X 0000000000 0000 0000000000 0000 0 0000000000000 000000 0000000000000 00000 0 00 00000000000 000000 000000 00000 00000000000 XX XXXX X XX XXXX 00000000000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 484 579 MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 485 579 MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 486 579 MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 487 579 MOA 3200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA 00 000000 XXX XXXXXX XXX XXX XXXX 00000000000 00 0000000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 488 579 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 489 579 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 IL 1 XXXXX X XXXXXX XXXX II XX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 490 579 NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 491 579 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3 X XX Max use 1 Optional N3-01 166 Other Insured Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 492 579 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4 XX XX XXXXXX XXX Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Insured City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Insured State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Insured Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 493 579 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 494 579 2330A Other Subscriber Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY XXX Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 495 579 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 PR 2 X PI XXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 496 579 Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 497 579 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N3 Other Payer Address To specify the location of the named party Usage notes 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. Example N3 XX XXXXXX Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 498 579 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XX XX XXXX XX Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 499 579 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 500 579 DTP 3500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP 573 D8 XXX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 501 579 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REF T4 XXXX Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Only allowed value is "Y". 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 502 579 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REF F8 XXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only. REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 503 579 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REF G1 XXXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 504 579 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF 9F X Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 505 579 2330B Other Payer Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF FY XXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 506 579 2330C Other Payer Attending Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Attending Provider Loop NM1 Other Payer Attending Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 71 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 71 Attending Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 507 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 508 579 2330C Other Payer Attending Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Attending Provider Loop REF Other Payer Attending Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU XXX Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Attending Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 509 579 2330D Other Payer Operating Physician Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Operating Physician Loop NM1 Other Payer Operating Physician To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 72 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_15 |
guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 507 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 508 579 2330C Other Payer Attending Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Attending Provider Loop REF Other Payer Attending Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU XXX Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Attending Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 509 579 2330D Other Payer Operating Physician Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Operating Physician Loop NM1 Other Payer Operating Physician To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 72 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 510 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 511 579 2330D Other Payer Operating Physician Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Operating Physician Loop REF Other Payer Operating Physician Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF G2 XXXX Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Operating Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 512 579 2330E Other Payer Other Operating Physician Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Other Operating Physician Loop NM1 Other Payer Other Operating Physician To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 ZZ 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 513 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 514 579 2330E Other Payer Other Operating Physician Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Other Operating Physician Loop REF Other Payer Other Operating Physician Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU XXXX Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Other Operating Physician Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 515 579 2330F Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 77 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 516 579 2 Non-Person Entity 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 517 579 2330F Other Payer Service Facility Location Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop REF Other Payer Service Facility Location Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF 0B XXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 518 579 2330G Other Payer Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Rendering Provider Name Loop NM1 Other Payer Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 82 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 519 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 520 579 2330G Other Payer Rendering Provider Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Rendering Provider Name Loop REF Other Payer Rendering Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU X Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Rendering Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 521 579 2330H Other Payer Referring Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Referring Provider Loop NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 DN 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 522 579 1 Person 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 523 579 2330H Other Payer Referring Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Referring Provider Loop REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF 0B XXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 524 579 2330I Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Billing Provider Loop NM1 Other Payer Billing Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 85 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 525 579 2 Non-Person Entity 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 526 579 2330I Other Payer Billing Provider Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Billing Provider Loop REF Other Payer Billing Provider Secondary Identification To specify identifying information Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF G2 XXXXXX Max use 2 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Billing Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 527 579 2400 Service Line Number Loop Max 999 Required LX 3650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX 0 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 528 579 SV2 3750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV2 Institutional Service Line To specify the service line item detail for a health care institution Example SV2 XX WK X XX XX XX XX XXXXX 000000 DA 00 00000 00000000 Max use 1 Required SV2-01 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SV201 is the revenue code. Usage notes See Code Source 132: National Uniform Billing Committee (NUBC) Codes. SV2-02 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Usage notes Required for outpatient claims when an appropriate procedure code exists for this service line item. OR Required for inpatient claims when an appropriate HCPCS (drugs and or biologics only) or HIPPS code exists for this service line item. If not required by this implementation guide, do not send.; Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product Service Code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 529 579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 530 579 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV2-03 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV203 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV2-04 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit SV2-05 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV2-07 782 Line Item Denied Charge or Non-Covered Charge Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 531 579 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK B4 FT AC XX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 532 579 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 533 579 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 534 579 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes Required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day. OR Required on service lines where a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written. If not required by this implementation guide, do not send. In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and 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 first day of the drug used by the patient is 1 1 00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was 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 supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1 1 00. In cases where a drug is being billed on a service line, a single date may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written). Example DTP 472 D8 XXX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 535 579 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 536 579 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9D XX Variants (all may be used) REF Line Item Control Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 537 579 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF 6R XXXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 538 579 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9B XXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Line Item Control Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 539 579 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Facility Tax Amount To indicate the total monetary amount Usage notes Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Facility Tax Amount. Example AMT N8 000000000000 Variants (all may be used) AMT Service Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount N8 Miscellaneous Taxes AMT-02 782 Facility Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 540 579 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Service Tax Amount To indicate the total monetary amount Usage notes Required when a service tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Service Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Service Tax Amount. Example AMT GT 00000000 Variants (all may be used) AMT Facility Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount GT Goods and Services Tax AMT-02 782 Service Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 541 579 NTE 4850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTE TPO XX Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 542 579 HCP 4920 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop HCP Line Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 01 0000 00 XXXXX 000000 XXXX 00 XX ER XXXX D A 00000 T1 4 1 If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Quantity (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 Pricing HCP-02 782 Monetary Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 543 579 HCP02 is the allowed amount. HCP-03 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Rate Min 1 Max 9 Decimal number (R) Optional Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 544 579 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Product or Service ID Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type source of the descriptive number used in Product Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 545 579 Identifying number for a product or service HCP10 is the approved procedure code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_16 |
Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type source of the descriptive number used in Product Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 545 579 Identifying number for a product or service HCP10 is the approved procedure code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 546 579 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 547 579 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop LIN Drug Identification To specify basic item identification data Usage notes Drugs and biologics reported in this segment are a further specification of service(s) described in the SV2 segment of this Service Line Loop ID-2400. Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. If not required by this implementation guide, do not send. Example LIN N4 XX Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) LIN02 through LIN31 provide for fifteen different product service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. N4 National Drug Code in 5-4-2 Format LIN-03 234 National Drug Code Min 1 Max 48 String (AN) Required Identifying number for a product or service 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 548 579 CTP 4940 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop CTP Drug Quantity To specify pricing information Example CTP 000000000000000 GR Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 549 579 2410 Drug Identification Loop end REF 4950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop REF Prescription or Compound Drug Association Number To specify identifying information Usage notes In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REF XZ XXXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 550 579 2420A Operating Physician Name Loop Max 1 Optional Variants (all may be used) Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Operating Physician Name Loop NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. AND The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level). If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Example NM1 72 1 XX XXXXX XXXX XXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 551 579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 552 579 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Operating Physician Name Loop REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF G2 XXXX 2U XXXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 553 579 2420A Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 554 579 2420B Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Other Operating Physician Name Loop NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved, AND The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level). If not required by this implementation guide, do not send.; Example NM1 ZZ 1 XXX XXXXXX X XX XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 555 579 Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 556 579 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Other Operating Physician Name Loop REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 0B XX 2U XXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 557 579 2420B Other Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 558 579 2420C Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim. AND State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) AND The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Example NM1 82 1 XXX X XXXXXX XXXXX XX XX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 559 579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 560 579 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF G2 XXXXXX 2U X Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 561 579 2420C Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 562 579 2420D Referring Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. AND The Referring Provider for this line is different than the Referring Provider reported in Loop ID 2310F (claim level). If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Example NM1 DN 1 XXXX XX X XXXXXX XX XX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 563 579 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 564 579 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF G2 X 2U XXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 565 579 2420D Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 566 579 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD XXXX 000000000000000 IV X XX XX XX XX XXXX XX XXX 00000000000 000000 Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Usage notes Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01). Max use 1 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 567 579 If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 568 579 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-04 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SVD04 is the revenue code. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 569 579 SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 570 579 CAS 5450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS CR XXX 00000000000000 000000000000000 X 00000 0 000000000000000 XXX 00000000000 0000000000000 0 X 000 0000000000000 XXXXX 00000000000000 000000 000000 X 00000 00000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 571 579 If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 572 579 CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 573 579 See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 574 579 DTP 5500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP 573 D8 XXXXXX Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 575 579 2430 Line Adjudication Information Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end 2000C Patient Hierarchical Level Loop end 2000B Subscriber Hierarchical Level Loop end AMT 5505 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 000000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 576 579 2000A Billing Provider Hierarchical Level Loop end Detail end SE 5550 Detail SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 00 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 577 579 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 000000 00000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 578 579 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 000 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 30 25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-institutional-x223a3 01H16H3T6ZSQSBCEV8FBKSZ4YX 579 579 | /kaggle/input/edi-db-835-837/Health Partner Plans 837 Health Care Claim_ Institutional.pdf | 4552e0b5e4bc9bebee7acbe3f3f1e672 | 4552e0b5e4bc9bebee7acbe3f3f1e672_17 |
Stedi maintains this guide based on public documentation from Home State Health. Contact Home State Health for official EDI specifications. To report any errors in this guide, please contact us. X12 837 Health Care Claim: Professional (X222A2) X12 Release 5010 Revised November 17, 2023 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care 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 billing information, 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 to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and or payment of health care services within a specific health care insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such 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 a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care insurance industry segment. Delimiters Segment Element Component Repetition 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 1 665 View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view home-state-health health-care-claim-professional- x222a2 01H25M3DFZT8BN5QV8WP430GEQ POWERED BY Build EDI implementation guides at stedi.com 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 2 665 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0050 Transaction Set Header Max use 1 Required BHT 0100 Beginning of Hierarchical Transaction Max use 1 Required Submitter Name Loop NM1 0200 Submitter Name Max use 1 Required PER 0450 Submitter EDI Contact Information Max use 2 Required Receiver Name Loop NM1 0200 Receiver Name Max use 1 Required Detail Billing Provider Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PRV 0030 Billing Provider Specialty Information Max use 1 Optional CUR 0100 Foreign Currency Information Max use 1 Optional Billing Provider Name Loop NM1 0150 Billing Provider Name Max use 1 Required N3 0250 Billing Provider Address Max use 1 Required N4 0300 Billing Provider City, State, ZIP Code Max use 1 Required REF 0350 Billing Provider Tax Identification Max use 1 Required REF 0350 Billing Provider UPIN License Information Max use 2 Optional PER 0400 Billing Provider Contact Information Max use 2 Optional Pay-to Address Name Loop NM1 0150 Pay-to Address Name Max use 1 Required N3 0250 Pay-to Address - ADDRESS Max use 1 Required N4 0300 Pay-To Address City, State, ZIP Code Max use 1 Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 3 665 Pay-To Plan Name Loop NM1 0150 Pay-To Plan Name Max use 1 Required N3 0250 Pay-to Plan Address Max use 1 Required N4 0300 Pay-To Plan City, State, ZIP Code Max use 1 Required REF 0350 Pay-to Plan Secondary Identification Max use 1 Optional REF 0350 Pay-To Plan Tax Identification Number Max use 1 Required Subscriber Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required SBR 0050 Subscriber Information Max use 1 Required PAT 0070 Patient Information Max use 1 Optional Subscriber Name Loop NM1 0150 Subscriber Name Max use 1 Required N3 0250 Subscriber Address Max use 1 Optional N4 0300 Subscriber City, State, ZIP Code Max use 1 Optional DMG 0320 Subscriber Demographic Information Max use 1 Optional REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Subscriber Secondary Identification Max use 1 Optional PER 0400 Property and Casualty Subscriber Contact Information Max use 1 Optional Payer Name Loop NM1 0150 Payer Name Max use 1 Required N3 0250 Payer Address Max use 1 Optional N4 0300 Payer City, State, ZIP Code Max use 1 Optional REF 0350 Billing Provider Secondary Identification Max use 2 Optional REF 0350 Payer Secondary Identification Max use 3 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Date - Accident Max use 1 Optional DTP 1350 Date - Acute Manifestation Max use 1 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 4 665 DTP 1350 Date - Admission Max use 1 Optional DTP 1350 Date - Assumed and Relinquished Care Dates Max use 2 Optional DTP 1350 Date - Authorized Return to Work Max use 1 Optional DTP 1350 Date - Disability Dates Max use 1 Optional DTP 1350 Date - Discharge Max use 1 Optional DTP 1350 Date - Hearing and Vision Prescription Date Max use 1 Optional DTP 1350 Date - Initial Treatment Date Max use 1 Optional DTP 1350 Date - Last Menstrual Period Max use 1 Optional DTP 1350 Date - Last Seen Date Max use 1 Optional DTP 1350 Date - Last Worked Max use 1 Optional DTP 1350 Date - Last X-ray Date Max use 1 Optional DTP 1350 Date - Onset of Current Illness or Symptom Max use 1 Optional DTP 1350 Date - Property and Casualty Date of First Contact Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Amount Paid Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Care Plan Oversight Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Mammography Certification Number Max use 1 Optional REF 1800 Mandatory Medicare (Section 4081) Crossover Indicator Max use 1 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 5 665 REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Claim Note Max use 1 Optional CR1 1950 Ambulance Transport Information Max use 1 Optional CR2 2000 Spinal Manipulation Service Information Max use 1 Optional CRC 2200 Ambulance Certification Max use 3 Optional CRC 2200 EPSDT Referral Max use 1 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 Patient Condition Information: Vision Max use 3 Optional HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Health Care Diagnosis Code Max use 1 Required HCP 2410 Claim Pricing Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required PRV 2550 Rendering Provider Specialty Information Max use 1 Optional REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 6 665 PER 2750 Service Facility Contact Information Max use 1 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 Optional Ambulance Pick-up Location Loop NM1 2500 Ambulance Pick-up Location Max use 1 Required N3 2650 Ambulance Pick-up Location Address Max use 1 Required N4 2700 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 2500 Ambulance Drop-off Location Max use 1 Required N3 2650 Ambulance Drop-off Location Address Max use 1 Required N4 2700 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 1 Optional Other Payer Name Loop 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 7 665 NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3450 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Rendering Provider Loop NM1 3250 Other Payer Rendering Provider Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 3 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Supervising Provider Loop NM1 3250 Other Payer Supervising Provider Max use 1 Required REF 3550 Other Payer Supervising Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 8 665 LX 3650 Service Line Number Max use 1 Required SV1 3700 Professional Service Max use 1 Required SV5 4000 Durable Medical Equipment Service Max use 1 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 Optional PWK 4200 Line Supplemental Information Max use 10 Optional CR1 4250 Ambulance Transport Information Max use 1 Optional CR3 4350 Durable Medical Equipment Certification Max use 1 Optional CRC 4500 Ambulance Certification Max use 3 Optional CRC 4500 Condition Indicator Durable Medical Equipment Max use 1 Optional CRC 4500 Hospice Employee Indicator Max use 1 Optional DTP 4550 Date - Begin Therapy Date Max use 1 Optional DTP 4550 DATE - Certification Revision Recertification Date Max use 1 Optional DTP 4550 Date - Initial Treatment Date Max use 1 Optional DTP 4550 Date - Last Certification Date Max use 1 Optional DTP 4550 Date - Last Seen Date Max use 1 Optional DTP 4550 Date - Last X-ray Date Max use 1 Optional DTP 4550 Date - Prescription Date Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Required DTP 4550 Date - Shipped Date Max use 1 Optional DTP 4550 Date - Test Date Max use 2 Optional QTY 4600 Ambulance Patient Count Max use 1 Optional QTY 4600 Obstetric Anesthesia Additional Units Max use 1 Optional MEA 4620 Test Result Max use 5 Optional CN1 4650 Contract Information Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 4700 Immunization Batch Number Max use 1 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 9 665 REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Mammography Certification Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional REF 4700 Referral Number Max use 5 Optional REF 4700 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Postage Claimed Amount Max use 1 Optional AMT 4750 Sales Tax Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional NTE 4850 Line Note Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional PS1 4880 Purchased Service Information Max use 1 Optional HCP 4920 Line Pricing Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required PRV 5050 Rendering Provider Specialty Information Max use 1 Optional REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Purchased Service Provider Name Loop NM1 5000 Purchased Service Provider Name Max use 1 Required REF 5250 Purchased Service Provider Secondary Identification Max use 20 Optional Service Facility Location Name Loop NM1 5000 Service Facility Location Name Max use 1 Required N3 5140 Service Facility Location Address Max use 1 Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 10 665 N4 5200 Service Facility Location City, State, ZIP Code Max use 1 Required REF 5250 Service Facility Location Secondary Identification Max use 3 Optional Supervising Provider Name Loop NM1 5000 Supervising Provider Name Max use 1 Required REF 5250 Supervising Provider Secondary Identification Max use 20 Optional Ordering Provider Name Loop NM1 5000 Ordering Provider Name Max use 1 Required N3 5140 Ordering Provider Address Max use 1 Optional N4 5200 Ordering Provider City, State, ZIP Code Max use 1 Optional REF 5250 Ordering Provider Secondary Identification Max use 20 Optional PER 5300 Ordering Provider Contact Information Max use 1 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Ambulance Pick-up Location Loop NM1 5000 Ambulance Pick-up Location Max use 1 Required N3 5140 Ambulance Pick-up Location Address Max use 1 Required N4 5200 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 5000 Ambulance Drop-off Location Max use 1 Required N3 5140 Ambulance Drop-off Location Address Max use 1 Required N4 5200 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 11 665 AMT 5505 Remaining Patient Liability Max use 1 Optional Form Identification Code Loop LQ 5510 Form Identification Code Max use 1 Required FRM 5520 Supporting Documentation Max use 99 Required Patient Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PAT 0070 Patient Information Max use 1 Required Patient Name Loop NM1 0150 Patient Name Max use 1 Required N3 0250 Patient Address Max use 1 Required N4 0300 Patient City, State, ZIP Code Max use 1 Required DMG 0320 Patient Demographic Information Max use 1 Required REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Property and Casualty Patient Identifier Max use 1 Optional PER 0400 Property and Casualty Patient Contact Information Max use 1 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Date - Accident Max use 1 Optional DTP 1350 Date - Acute Manifestation Max use 1 Optional DTP 1350 Date - Admission Max use 1 Optional DTP 1350 Date - Assumed and Relinquished Care Dates Max use 2 Optional DTP 1350 Date - Authorized Return to Work Max use 1 Optional DTP 1350 Date - Disability Dates Max use 1 Optional DTP 1350 Date - Discharge Max use 1 Optional DTP 1350 Date - Hearing and Vision Prescription Date Max use 1 Optional DTP 1350 Date - Initial Treatment Date Max use 1 Optional DTP 1350 Date - Last Menstrual Period Max use 1 Optional DTP 1350 Date - Last Seen Date Max use 1 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 12 665 DTP 1350 Date - Last Worked Max use 1 Optional DTP 1350 Date - Last X-ray Date Max use 1 Optional DTP 1350 Date - Onset of Current Illness or Symptom Max use 1 Optional DTP 1350 Date - Property and Casualty Date of First Contact Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Amount Paid Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Care Plan Oversight Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Mammography Certification Number Max use 1 Optional REF 1800 Mandatory Medicare (Section 4081) Crossover Indicator Max use 1 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Claim Note Max use 1 Optional CR1 1950 Ambulance Transport Information Max use 1 Optional CR2 2000 Spinal Manipulation Service Information Max use 1 Optional CRC 2200 Ambulance Certification Max use 3 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 13 665 CRC 2200 EPSDT Referral Max use 1 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 Patient Condition Information: Vision Max use 3 Optional HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Health Care Diagnosis Code Max use 1 Required HCP 2410 Claim Pricing Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required PRV 2550 Rendering Provider Specialty Information Max use 1 Optional REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional PER 2750 Service Facility Contact Information Max use 1 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 Optional Ambulance Pick-up Location Loop NM1 2500 Ambulance Pick-up Location Max use 1 Required N3 2650 Ambulance Pick-up Location Address Max use 1 Required N4 2700 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 14 665 Ambulance Drop-off Location Loop NM1 2500 Ambulance Drop-off Location Max use 1 Required N3 2650 Ambulance Drop-off Location Address Max use 1 Required N4 2700 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 1 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3450 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 15 665 Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Rendering Provider Loop NM1 3250 Other Payer Rendering Provider Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 3 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Supervising Provider Loop NM1 3250 Other Payer Supervising Provider Max use 1 Required REF 3550 Other Payer Supervising Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV1 3700 Professional Service Max use 1 Required SV5 4000 Durable Medical Equipment Service Max use 1 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 Optional PWK 4200 Line Supplemental Information Max use 10 Optional CR1 4250 Ambulance Transport Information Max use 1 Optional CR3 4350 Durable Medical Equipment Certification Max use 1 Optional CRC 4500 Ambulance Certification Max use 3 Optional CRC 4500 Condition Indicator Durable Medical Equipment Max use 1 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 16 665 CRC 4500 Hospice Employee Indicator Max use 1 Optional DTP 4550 Date - Begin Therapy Date Max use 1 Optional DTP 4550 DATE - Certification Revision Recertification Date Max use 1 Optional DTP 4550 Date - Initial Treatment Date Max use 1 Optional DTP 4550 Date - Last Certification Date Max use 1 Optional DTP 4550 Date - Last Seen Date Max use 1 Optional DTP 4550 Date - Last X-ray Date Max use 1 Optional DTP 4550 Date - Prescription Date Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Required DTP 4550 Date - Shipped Date Max use 1 Optional DTP 4550 Date - Test Date Max use 2 Optional QTY 4600 Ambulance Patient Count Max use 1 Optional QTY 4600 Obstetric Anesthesia Additional Units Max use 1 Optional MEA 4620 Test Result Max use 5 Optional CN1 4650 Contract Information Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 4700 Immunization Batch Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Mammography Certification Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional REF 4700 Referral Number Max use 5 Optional REF 4700 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Postage Claimed Amount Max use 1 Optional AMT 4750 Sales Tax Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 17 665 NTE 4850 Line Note Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional PS1 4880 Purchased Service Information Max use 1 Optional HCP 4920 Line Pricing Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required PRV 5050 Rendering Provider Specialty Information Max use 1 Optional REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Purchased Service Provider Name Loop NM1 5000 Purchased Service Provider Name Max use 1 Required REF 5250 Purchased Service Provider Secondary Identification Max use 20 Optional Service Facility Location Name Loop NM1 5000 Service Facility Location Name Max use 1 Required N3 5140 Service Facility Location Address Max use 1 Required N4 5200 Service Facility Location City, State, ZIP Code Max use 1 Required REF 5250 Service Facility Location Secondary Identification Max use 3 Optional Supervising Provider Name Loop NM1 5000 Supervising Provider Name Max use 1 Required REF 5250 Supervising Provider Secondary Identification Max use 20 Optional Ordering Provider Name Loop NM1 5000 Ordering Provider Name Max use 1 Required N3 5140 Ordering Provider Address Max use 1 Optional N4 5200 Ordering Provider City, State, ZIP Code Max use 1 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 18 665 REF 5250 Ordering Provider Secondary Identification Max use 20 Optional PER 5300 Ordering Provider Contact Information Max use 1 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Ambulance Pick-up Location Loop NM1 5000 Ambulance Pick-up Location Max use 1 Required N3 5140 Ambulance Pick-up Location Address Max use 1 Required N4 5200 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 5000 Ambulance Drop-off Location Max use 1 Required N3 5140 Ambulance Drop-off Location Address Max use 1 Required N4 5200 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional Form Identification Code Loop LQ 5510 Form Identification Code Max use 1 Required FRM 5520 Supporting Documentation Max use 99 Required SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 19 665 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250131 0243 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 20 665 Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 21 665 Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 22 665 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HC XXXXXXX XXXXXXX 20250130 0541 00 XX 005010X 222A2 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HC Health Care Claim (837) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 23 665 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X222A2 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 24 665 Heading ST 0050 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 837 0001 005010X222A2 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). 837 Health Care Claim ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. ST-03 1705 Implementation Guide Version Name String (AN) Required Reference assigned to identify Implementation Convention The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08. Usage notes This element must be populated with the guide identifier named in Section 1.2. This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time. 005010X222A2 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 25 665 BHT 0100 Heading BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT 0019 18 XXXXX 20250130 0700 31 Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. 18 Reissue If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent. BHT-03 127 Originator Application Transaction Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 26 665 BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time Time (TM) Required HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim or Encounter Identifier Identifier (ID) Required Code specifying the type of transaction 31 Subrogation Demand The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners. NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction. CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. RP Reporting Use RP when the entire ST-SE envelope contains only capitated encounters. Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 27 665 1000A Submitter Name Loop Max 1 Required Variants (all may be used) Receiver Name Loop NM1 0200 Heading Submitter Name Loop NM1 Submitter Name To supply the full name of an individual or organizational entity Usage notes The submitter is the entity responsible for the creation and formatting of this transaction. Example NM1 41 2 XXXXX X X 46 XX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 41 Submitter NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Submitter Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Submitter First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Submitter Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-08 66 Identification Code Qualifier Identifier (ID) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 28 665 Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) Established by trading partner agreement NM1-09 67 Submitter Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 29 665 PER 0450 Heading Submitter Name Loop PER Submitter EDI Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER IC X FX X TE XXX TE XXXXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Submitter Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 30 665 1000A Submitter Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 31 665 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop 1000B Receiver Name Loop end NM1 0200 Heading Receiver Name Loop NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1 40 2 XXXXXX 46 XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 40 Receiver NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Receiver Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 32 665 Heading end 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 33 665 Detail 2000A Billing Provider Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 1 20 1 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_0 |
Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 31 665 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop 1000B Receiver Name Loop end NM1 0200 Heading Receiver Name Loop NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1 40 2 XXXXXX 46 XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 40 Receiver NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Receiver Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 32 665 Heading end 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 33 665 Detail 2000A Billing Provider Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 1 20 1 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 34 665 PRV 0030 Detail Billing Provider Hierarchical Level Loop PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRV BI PXC XX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 35 665 CUR 0100 Detail Billing Provider Hierarchical Level Loop CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send. It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars. Example CUR 85 XXX Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD Canadian dollars would be valid, while CA Canada would be invalid. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 36 665 2010AA Billing Provider Name Loop Max 1 Required Variants (all may be used) Pay-to Address Name Loop Pay-To Plan Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop NM1 Billing Provider Name To supply the full name of an individual or organizational entity Usage notes Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID- 2010BB. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop. The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration). When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. Example NM1 85 2 XXXXXX X XXX XXXXX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 37 665 NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Billing Provider Last or Organizational Name String (AN) Required Min 1 Max 60 Individual last name or organizational name NM1-04 1036 Billing Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Billing Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Billing Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Billing Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 38 665 N3 0250 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N3 Billing Provider Address To specify the location of the named party Usage notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3 X X Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 39 665 N4 0300 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXX XX Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Billing Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Billing Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Billing Provider Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 40 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 41 665 REF 0350 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop REF Billing Provider Tax Identification To specify identifying information Usage notes This is the tax identification number (TIN) of the entity to be paid for the submitted services. Example REF SY XXX Variants (all may be used) REF Billing Provider UPIN License Information Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Billing Provider Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 42 665 REF 0350 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop REF Billing Provider UPIN License Information To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and or license number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification. Example REF 0B XXXXXX Variants (all may be used) REF Billing Provider Tax Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. REF-02 127 Billing Provider License and or UPIN Information String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 43 665 PER 0400 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.; When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER IC XXXXXX EM XXX EM XXXXX FX X If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Billing Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 44 665 2010AA Billing Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 45 665 2010AB Pay-to Address Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-To Plan Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information. Example NM1 87 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 87 Pay-to Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 46 665 N3 0250 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop N3 Pay-to Address - ADDRESS To specify the location of the named party Example N3 XXXXX X Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 47 665 N4 0300 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop N4 Pay-To Address City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXXX XX XXXXX XXX Only one of Pay-to Address State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-to Address City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-to Address State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-to Address Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 48 665 2010AB Pay-to Address Name Loop end 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 49 665 2010AC Pay-To Plan Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-to Address Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop NM1 Pay-To Plan Name To supply the full name of an individual or organizational entity Usage notes Required when willing trading partners agree to use this implementation for their subrogation payment requests. This loop may only be used when BHT06 31. Example NM1 PE 2 X XV XX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee PE is used to indicate the subrogated payee. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Pay-To Plan Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 50 665 Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Pay-To Plan Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 51 665 N3 0250 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop N3 Pay-to Plan Address To specify the location of the named party Example N3 XXXX XXXXX Max use 1 Required N3-01 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 52 665 N4 0300 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop N4 Pay-To Plan City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXX XX XXXX XX Only one of Pay-To Plan State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-To Plan City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-To Plan State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-To Plan Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 53 665 REF 0350 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop REF Pay-to Plan Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF FY XX Variants (all may be used) REF Pay-To Plan Tax Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Pay-to Plan Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 54 665 2010AC Pay-To Plan Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop REF Pay-To Plan Tax Identification Number To specify identifying information Example REF EI XXX Variants (all may be used) REF Pay-to Plan Secondary Identification Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Pay-To Plan Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 55 665 2000B Subscriber Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 2 1 22 1 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 22 Subscriber HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 56 665 0 No Subordinate HL Segment in This Hierarchical Structure. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 57 665 SBR 0050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBR B 18 XXXXX XXXXX 42 VA Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. 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 This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 58 665 This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 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) Medicare Risk 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 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 59 665 ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 60 665 PAT 0070 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop PAT Patient Information To supply patient information Usage notes Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met. If not required by this implementation guide, do not send. Example PAT D8 XXXX 01 0000 Y If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required Max use 1 Optional PAT-05 1250 Date Time Period Format Qualifier Identifier (ID) Optional Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD PAT-06 1251 Patient Death Date Min 1 Max 35 String (AN) Optional Expression of a date, a time, or range of dates, times or dates and times PAT06 is the date of death. PAT-07 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken 01 Actual Pounds PAT-08 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight PAT08 is the patient's weight. PAT-09 1073 Pregnancy Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant. Usage notes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 61 665 For this implementation, the listed value takes precedence over the semantic note. Y Yes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 62 665 2010BA Subscriber Name Loop Max 1 Required Variants (all may be used) Payer Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes 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. Example NM1 IL 1 XXXXX XXX XXXX XXX MI XXXXXX If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 63 665 Individual middle name or initial NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 64 665 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3 XXXX XXXX Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Subscriber Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 65 665 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop N4 Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4 XXX XX XXXXXX XX Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Subscriber State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 66 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 67 665 DMG 0320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop DMG Subscriber Demographic Information To supply demographic information Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example DMG D8 XXX F Max use 1 Optional DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Subscriber Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Subscriber Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 68 665 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop REF Property and Casualty Claim Number To specify identifying information Usage notes Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Example REF Y4 X Variants (all may be used) REF Subscriber Secondary Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 69 665 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop REF Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY X Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Subscriber Supplemental Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 70 665 PER 0400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop PER Property and Casualty Subscriber Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC XXXX TE XXX EX X If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 71 665 2010BA Subscriber Name Loop end Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 72 665 2010BB Payer Name Loop Max 1 Required Variants (all may be used) Subscriber Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop NM1 Payer Name To supply the full name of an individual or organizational entity Usage notes This is the destination payer. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator. Example NM1 PR 2 XXX XV XXXXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 73 665 Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Payer Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 74 665 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N3 Payer Address To specify the location of the named party Usage notes 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. Example N3 XXXXX XXXXXX Max use 1 Optional N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 75 665 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_1 |
Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop NM1 Payer Name To supply the full name of an individual or organizational entity Usage notes This is the destination payer. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator. Example NM1 PR 2 XXX XV XXXXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 73 665 Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Payer Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 74 665 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N3 Payer Address To specify the location of the named party Usage notes 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. Example N3 XXXXX XXXXXX Max use 1 Optional N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 75 665 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XXXX XX XXXX XXX Only one of Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 76 665 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 77 665 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop REF Billing Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU X Variants (all may be used) REF Payer Secondary Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Billing Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 78 665 2010BB Payer Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop REF Payer Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF FY XXXX Variants (all may be used) REF Billing Provider Secondary Identification Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 79 665 2300 Claim Information Loop Max 100 Optional CLM 1300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. 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 hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLM XXXXXX 00000000000 XX B X N B N Y P OA XXX XX XX 02 5 Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is 20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 80 665 CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim. CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Place of Service Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. B Place of Service Codes for Professional or Dental Services C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes Must contain a value for the National UB Data Element Specification Type List Type of Bill Position 3 CLM-06 1073 Provider or Supplier Signature Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file. N No Y Yes CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 81 665 Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 82 665 I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-10 1351 Patient Signature Source Code Identifier (ID) Optional Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. CLM-11 C024 Related Causes Information To identify one or more related causes and associated state or country information Usage notes Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send. Max use 1 Optional C024-01 1362 Related Causes Code Identifier (ID) Required Code identifying an accompanying cause of an illness, injury or an accident AA Auto Accident EM Employment OA Other Accident C024-02 1362 Related Causes Code Min 2 Max 3 Identifier (ID) Optional Code identifying an accompanying cause of an illness, injury or an accident C024-04 156 Auto Accident State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA". C024-05 26 Country Code Min 2 Max 3 Identifier (ID) Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 83 665 Code identifying the country CLM-12 1366 Special Program Indicator Identifier (ID) Optional Code indicating the Special Program under which the services rendered to the patient were performed 02 Physically Handicapped Children's Program This code is used for Medicaid claims only. 03 Special Federal Funding This code is used for Medicaid claims only. 05 Disability This code is used for Medicaid claims only. 09 Second Opinion or Surgery This code is used for Medicaid claims only. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 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 Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 84 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Accident To specify any or all of a date, a time, or a time period Usage notes Required when CLM11-1 or CLM11-2 has a value of AA' or OA'. OR Required when CLM11-1 or CLM11-2 has a value of EM' and this claim is the result of an accident. If not required by this implementation guide, do not send. Example DTP 439 D8 XX Variants (all may be used) DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 439 Accident DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Accident Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 85 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 86 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Acute Manifestation To specify any or all of a date, a time, or a time period Usage notes Required when Loop ID-2300 CR208 "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send. Example DTP 453 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 453 Acute Manifestation of a Chronic Condition DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Acute Manifestation Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 87 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 88 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Admission To specify any or all of a date, a time, or a time period Usage notes Required on all ambulance claims when the patient was known to be admitted to the hospital. OR Required on all claims involving inpatient medical visits. If not required by this implementation guide, do not send. Example DTP 435 D8 XXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Admission Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 89 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 90 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Assumed and Relinquished Care Dates To specify any or all of a date, a time, or a time period Usage notes Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send. Assumed Care Date is the date care was assumed by another provider during post- operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A". Example DTP 090 D8 XXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 090 Report Start Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care. 091 Report End Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 91 665 DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Assumed or Relinquished Care Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 92 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Authorized Return to Work To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP 296 D8 XX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 296 Initial Disability Period Return To Work This is the date the provider has authorized the patient to return to work. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Work Return Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 93 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 94 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Disability Dates To specify any or all of a date, a time, or a time period Usage notes Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his her work. OR Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor. If not required by this implementation guide, do not send. Example DTP 314 RD8 XX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 314 Disability Use code 314 when both disability start and end date are being reported. 360 Initial Disability Period Start Use code 360 if patient is currently disabled and disability end date is unknown. 361 Initial Disability Period End Use code 361 if patient is no longer disabled and the start date is unknown. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 95 665 Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD Use code D8 when DTP01 is 360 or 361. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use code RD8 when DTP01 is 314. DTP-03 1251 Disability From Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 96 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Discharge To specify any or all of a date, a time, or a time period Usage notes Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send. Example DTP 096 D8 XXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Discharge Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 97 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 98 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Hearing and Vision Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send. Example DTP 471 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 99 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 100 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 454 D8 XXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 101 665 DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 102 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Last Menstrual Period To specify any or all of a date, a time, or a time period Usage notes Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send. Example DTP 484 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 484 Last Menstrual Period DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Menstrual Period Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 103 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 104 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 304 D8 X Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 105 665 D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Seen Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 106 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Last Worked To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP 297 D8 XX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 297 Initial Disability Period Last Day Worked DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Worked Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 107 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 108 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 455 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 109 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 110 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Onset of Current Illness or Symptom To specify any or all of a date, a time, or a time period Usage notes Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send. This date is the onset of acute symptoms for the current illness or condition. Example DTP 431 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 431 Onset of Current Symptoms or Illness DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Onset of Current Illness or Injury Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 111 665 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 112 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Property and Casualty Date of First Contact To specify any or all of a date, a time, or a time period Usage notes Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send. This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date. Example DTP 444 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 444 First Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Date Time Period Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 113 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_2 |
- Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 431 Onset of Current Symptoms or Illness DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Onset of Current Illness or Injury Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 111 665 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 112 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Property and Casualty Date of First Contact To specify any or all of a date, a time, or a time period Usage notes Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send. This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date. Example DTP 444 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 444 First Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Date Time Period Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 113 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 114 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP 050 D8 XXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 115 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 116 665 PWK 1550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK I5 EM AC XXXXXX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 117 665 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 118 665 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 119 665 CN1 1600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet 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. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN1 03 0000000000 0000 XXXX 00000 X Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 120 665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 121 665 AMT 1750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop AMT Patient Amount Paid To indicate the total monetary amount Usage notes Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s). Example AMT F5 00 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F5 Patient Amount Paid AMT-02 782 Patient Amount Paid Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 122 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF 9C XXXXX Variants (all may be used) REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 123 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Care Plan Oversight To specify identifying information Usage notes Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send. This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished. Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number. On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI. Example REF 1J XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1J Facility ID Number REF-02 127 Care Plan Oversight Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 124 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REF D9 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 30 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 125 665 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 126 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line. In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400. Example REF X4 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number String (AN) Required Min 1 Max 50 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 127 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 128 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF P4 XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 129 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REF LX XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 130 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send. Example REF EW XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 131 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Mandatory Medicare (Section 4081) Crossover Indicator To specify identifying information Usage notes Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send. Example REF F5 XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F5 Medicare Version Code REF-02 127 Medicare Section 4081 Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The allowed values for this element are: Y 4081 N Regular crossover 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 132 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REF EA XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 133 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF F8 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 134 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF G1 XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 135 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 136 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF 9F XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 137 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 138 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF 9A XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 139 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF 4N X Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Allowable values for this element are: 1 Immediate Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 140 665 6 Request for Override Pending 7 Special Handling 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 141 665 K3 1850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop K3 File Information To transmit a fixed-format record or matrix contents Usage notes 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. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3 XXXX Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 142 665 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTE CER XXXXXX Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information CER Certification Narrative DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description TPO Third Party Organization Notes NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 143 665 CR1 1950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send. The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101. Example CR1 LB 0000 E DH 000000000000 XX XXXX If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both Can be used to indicate that the patient was transferred to a residential facility. B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 144 665 Numeric value of quantity CR106 is the distance traveled during transport. Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 145 665 CR2 2000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CR2 Spinal Manipulation Service Information To supply information related to the chiropractic service rendered to a patient Usage notes Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. Example CR2 A XXXXXX XXXX Max use 1 Optional CR2-08 1342 Patient Condition Code Identifier (ID) Required Code indicating the nature of a patient's condition A Acute Condition C Chronic Condition D Non-acute E Non-Life Threatening F Routine G Symptomatic M Acute Manifestation of a Chronic Condition CR2-10 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR210 is a description of the patient's condition. CR2-11 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR211 is an additional description of the patient's condition. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 146 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC Ambulance Certification To supply information on conditions Usage notes Required when the claim involves ambulance transport services AND when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send. The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01. Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07. Example CRC 07 Y 01 XX XXX XX XX Variants (all may be used) CRC EPSDT Referral CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 147 665 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 148 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC EPSDT Referral To supply information on conditions Usage notes Required on Early Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRC ZZ Y S2 XX XXX Variants (all may be used) CRC Ambulance Certification CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 149 665 NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 150 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC Homebound Indicator To supply information on conditions Usage notes Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send. Example CRC 75 Y IH Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 75 Functional Limitations CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Y Yes CRC-03 1321 Homebound Indicator Identifier (ID) Required Code indicating a condition IH Independent at Home 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 151 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC Patient Condition Information: Vision To supply information on conditions Usage notes Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send. Example CRC E1 N L5 XX XX XX XXX Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Homebound Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. E1 Spectacle Lenses E2 Contact Lenses E3 Spectacle Frames CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition L1 General Standard of 20 Degree or.5 Diopter Sphere or Cylinder Change Met L2 Replacement Due to Loss or Theft L3 Replacement Due to Breakage or Damage L4 Replacement Due to Patient Preference L5 Replacement Due to Medical Reason CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_3 |
notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 150 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC Homebound Indicator To supply information on conditions Usage notes Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send. Example CRC 75 Y IH Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 75 Functional Limitations CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Y Yes CRC-03 1321 Homebound Indicator Identifier (ID) Required Code indicating a condition IH Independent at Home 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 151 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC Patient Condition Information: Vision To supply information on conditions Usage notes Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send. Example CRC E1 N L5 XX XX XX XXX Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Homebound Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. E1 Spectacle Lenses E2 Contact Lenses E3 Spectacle Frames CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition L1 General Standard of 20 Degree or.5 Diopter Sphere or Cylinder Change Met L2 Replacement Due to Loss or Theft L3 Replacement Due to Breakage or Damage L4 Replacement Due to Patient Preference L5 Replacement Due to Medical Reason CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 152 665 Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 153 665 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Anesthesia Related Procedure To supply information related to the delivery of health care Usage notes Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code. If not required by this implementation guide, do not send. Example HI BP X BO XXXX Variants (all may be used) HI Condition Information HI Health Care Diagnosis Code Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BP Health Care Financing Administration Common Procedural Coding System Principal Procedure C022-02 1271 Anesthesia Related Surgical Procedure String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 154 665 BO Health Care Financing Administration Common Procedural Coding System C022-02 1271 Industry Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 155 665 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Condition Information To supply information related to the delivery of health care Usage notes Required when condition information applies to the claim. If not required by this implementation guide, do not send. Example HI BG XXXX BG XX BG XXXXX BG X BG X BG XX BG XX B G XXXXX BG XXXXX BG XXX BG XXXXX BG XXXX Variants (all may be used) HI Anesthesia Related Procedure HI Health Care Diagnosis Code Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 156 665 BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 157 665 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 158 665 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 159 665 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 160 665 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 161 665 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Health Care Diagnosis Code To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BK XXX BF XXX BF XX BF XXXXX ABF XXXX BF XXXX X BF X ABF XXX BF XX BF X ABF XXXXX BF X Variants (all may be used) HI Anesthesia Related Procedure HI Condition Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 162 665 C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 163 665 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 164 665 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information Max use 1 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 165 665 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis ICD-9 Codes C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 166 665 OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 167 665 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 168 665 HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 169 665 HCP 2410 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HCP Claim Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 10 00000000000000 00 XXXX 00000 XXXX 00000000 00 T4 3 1 Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 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 Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 170 665 HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved Ambulatory Patient Group Code String (AN) Optional Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Ambulatory Patient Group Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount HCP07 is the approved DRG amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-13 901 Reject Reason Code Identifier (ID) Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 171 665 Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 172 665 2310A Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required when this claim involves a referral. If not required by this implementation guide, do not send. When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed reported in this transaction. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 DN 1 XXXX XXX XXXXXX XXX XX XXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 173 665 NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 174 665 2310A Referring Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 0B XXXX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 175 665 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, do not send. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 82 2 XXX XXX XXXXXX X XX XX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 176 665 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 177 665 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop PRV Rendering Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01. Example PRV PE PXC XXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 178 665 2310B Rendering Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU X Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 179 665 2310C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 77 2 XXXXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 180 665 NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_4 |
NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU X Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 179 665 2310C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 77 2 XXXXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 180 665 NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 181 665 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXX XXX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 182 665 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXXX XX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 183 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 184 665 REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU XXXX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 185 665 PER 2750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop PER Service Facility Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is different than the information provided in Loop ID-1000A Submitter EDI Contact Information PER Segment, and Loop ID-2010AA Billing Provider Contact Information PER segment and when deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC XXXX TE XXXXX EX XXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 186 665 2310C Service Facility Location Name Loop end PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 187 665 2310D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Supervising Provider Name Loop NM1 Supervising Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 DQ 1 XXXXXX XX XXX XXX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Supervising Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 188 665 Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 189 665 2310D Supervising Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Supervising Provider Name Loop REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF 0B XXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 190 665 2310E Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Pick-up Location Loop NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 PW 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 191 665 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Pick-up Location Loop N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXXXX X Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 192 665 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Pick-up Location Loop N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXXXXXX XXX Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 193 665 2310E Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 194 665 2310F Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Drop-off Location Loop NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 45 2 X Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 195 665 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Drop-off Location Loop N3 Ambulance Drop-off Location Address To specify the location of the named party Example N3 XXXXXX XX Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 196 665 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Drop-off Location Loop N4 Ambulance Drop-off Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXXX XX Only one of Ambulance Drop-off State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Drop-off City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Drop-off State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Drop-off Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 197 665 2310F Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 198 665 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR B 19 XXXX XXXXX 14 TV Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. 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 This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 199 665 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 200 665 16 Health Maintenance Organization (HMO) Medicare Risk 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 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 201 665 CAS 2950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS OA XXXX 0000 0000000 XXX 00000000000000 00000 0000000000 XXXXX 0000000000 00000000000 XXXX 0000 00000000 00000 XXXX 00 0000 XXXX 0000000 00000000 000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 202 665 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 203 665 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 204 665 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 205 665 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT D 00000000 Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 206 665 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT A8 0 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 207 665 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 208 665 OI 3100 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI W P I Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes OI-04 1351 Patient Signature Source Code Identifier (ID) Optional Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider Usage notes This is a crosswalk from CLM10 when doing COB. P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 209 665 Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 210 665 MOA 3200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA 0000000000 00000000000000 XXX XXXX XXXXX XXX X X 0000000000 0000000000000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 211 665 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 212 665 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 IL 1 XX XXXX XX XXXX II XXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 213 665 Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 214 665 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3 XXXXXX XXX Max use 1 Optional N3-01 166 Other Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 215 665 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4 XXX XX XXXXXXXX XX Only one of Other Subscriber State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Subscriber State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 216 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 217 665 2330A Other Subscriber Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY XXXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 218 665 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_5 |
guide, do not send. Example N4 XXX XX XXXXXXXX XX Only one of Other Subscriber State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Subscriber State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 216 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 217 665 2330A Other Subscriber Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY XXXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 218 665 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 PR 2 X PI XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 219 665 (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 220 665 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N3 Other Payer Address To specify the location of the named party Usage notes 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. Example N3 XXXXX XXXX Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 221 665 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XX XX XXX XXX Only one of Other Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 222 665 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 223 665 DTP 3450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP 573 D8 XXXXXX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 224 665 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REF T4 XX Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The only valid value for this element is Y'. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 225 665 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REF F8 XXXXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 226 665 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REF G1 XX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 227 665 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF 9F X Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 228 665 2330B Other Payer Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF FY XX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 229 665 2330C Other Payer Referring Provider Loop Max 2 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Referring Provider Loop NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 P3 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 230 665 1 Person 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 231 665 2330C Other Payer Referring Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Referring Provider Loop REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF 0B X Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 232 665 2330D Other Payer Rendering Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Rendering Provider Loop NM1 Other Payer Rendering Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 82 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 233 665 2330D Other Payer Rendering Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Rendering Provider Loop REF Other Payer Rendering Provider Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU XXXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Rendering Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 234 665 2330E Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 77 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 235 665 2330E Other Payer Service Facility Location Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop REF Other Payer Service Facility Location Secondary Identification To specify identifying information Example REF LU XXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 236 665 2330F Other Payer Supervising Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Supervising Provider Loop NM1 Other Payer Supervising Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 DQ 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 237 665 2330F Other Payer Supervising Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Supervising Provider Loop REF Other Payer Supervising Provider Secondary Identification To specify identifying information Example REF 0B X Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Supervising Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 238 665 2330G Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Billing Provider Loop NM1 Other Payer Billing Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 85 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 239 665 2330G Other Payer Billing Provider Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Billing Provider Loop REF Other Payer Billing Provider Secondary Identification To specify identifying information Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU XX Max use 2 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Billing Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 240 665 2400 Service Line Number Loop Max 50 Required LX 3650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX 00000 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 241 665 SV1 3700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV1 Professional Service To specify the service line item detail for a health care professional Example SV1 ER XXXX XX XX XX XX XXXX 000000 MJ 0000000000 00 XX 0 00 0 0 Y Y Y 0 Max use 1 Required SV1-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting or adjudication processes. The NDC number is reported in the LIN segment of Loop ID- 2410 only. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 242 665 By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV1-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 243 665 Monetary amount SV102 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and or postage claimed amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV1-03 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes Required for Anesthesia claims. Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre- anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel. UN Unit SV1-04 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV1-05 1331 Place of Service Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. SV105 is the place of service. Usage notes See CODE SOURCE 237: Place of Service Codes for Professional Claims SV1-07 C004 Composite Diagnosis Code Pointer To identify one or more diagnosis code pointers Max use 1 Required C004-01 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Required 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 244 665 A pointer to the diagnosis code in the order of importance to this service C004-01 identifies the primary diagnosis code for this service line. Usage notes This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300. C004-02 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-02 identifies the second diagnosis code for this service line. C004-03 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-03 identifies the third diagnosis code for this service line. C004-04 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-04 identifies the fourth diagnosis code for this service line. SV1-09 1073 Emergency Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related. Usage notes For this implementation, the listed value takes precedence over the semantic note. Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Y Yes SV1-11 1073 EPSDT Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 245 665 When this element is used, this service is not the screening service. Y Yes SV1-12 1073 Family Planning Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes SV1-15 1327 Co-Pay Status Code Identifier (ID) Optional Code indicating whether or not co-payment requirements were met on a line by line basis 0 Copay exempt 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 246 665 SV5 4000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV5 Durable Medical Equipment Service To specify the claim service detail for durable medical equipment Usage notes Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send. Example SV5 HC XXXXXX DA 0000000 00000000000000 000000 6 Max use 1 Optional SV5-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Procedure Identifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This value must be the same as that reported in SV101-2. SV5-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days SV5-03 380 Length of Medical Necessity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 247 665 SV503 is the length of medical treatment required. SV5-04 782 DME Rental Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV504 is the rental price. SV5-05 782 DME Purchase Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV505 is the purchase price. SV5-06 594 Rental Unit Price Indicator Identifier (ID) Required Code indicating frequency or type of activities or actions being reported SV506 is the frequency at which the rental equipment is billed. 1 Weekly 4 Monthly 6 Daily 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 248 665 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Durable Medical Equipment Certificate of Medical Necessity Indicator To identify the type or transmission or both of paperwork or supporting information Usage notes Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.; Example PWK CT AG Variants (all may be used) PWK Line Supplemental Information Max use 1 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item CT Certification PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AB Previously Submitted to Payer AD Certification Included in this Claim AF Narrative Segment Included in this Claim AG No Documentation is Required NS Not Specified NS Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 249 665 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK AS EL AC XXXX Variants (all may be used) PWK Durable Medical Equipment Certificate of Medical Necessity Indicator If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 250 665 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AA Available on Request at Provider Site 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 251 665 This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 252 665 CR1 4250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_6 |
Testing Results 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 250 665 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AA Available on Request at Provider Site 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 251 665 This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 252 665 CR1 4250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CR1 LB 0000000 A DH 00000 X XXXX If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CR106 is the distance traveled during transport. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 253 665 Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 254 665 CR3 4350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CR3 Durable Medical Equipment Certification To supply information regarding a physician's certification for durable medical equipment Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example CR3 R MO 000000000000000 Max use 1 Optional CR3-01 1322 Certification Type Code Identifier (ID) Required Code indicating the type of certification I Initial R Renewal S Revised CR3-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken CR302 and CR303 specify the time period covered by this certification. MO Months CR3-03 380 Durable Medical Equipment Duration Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Length of time DME equipment is needed. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 255 665 CRC 4500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CRC Ambulance Certification To supply information on conditions Usage notes The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CRC 07 Y 12 XX XX XX XX Variants (all may be used) CRC Condition Indicator Durable Medical Equipment CRC Hospice Employee Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 256 665 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 257 665 CRC 4500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CRC Condition Indicator Durable Medical Equipment To supply information on conditions Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The first example shows a case where an item billed was not a replacement item. Example CRC 09 N ZV XX Variants (all may be used) CRC Ambulance Certification CRC Hospice Employee Indicator Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 09 Durable Medical Equipment Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 38 Certification signed by the physician is on file at the supplier's office ZV Replacement Item CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 258 665 Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 259 665 CRC 4500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CRC Hospice Employee Indicator To supply information on conditions Usage notes Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The example shows the method used to indicate whether the rendering provider is an employee of the hospice. Example CRC 70 Y 65 Variants (all may be used) CRC Ambulance Certification CRC Condition Indicator Durable Medical Equipment Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 70 Hospice CRC-02 1073 Hospice Employed Provider Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes A "Y" value indicates the provider is employed by the hospice. A "N" value indicates the provider is not employed by the hospice. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 260 665 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 261 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Begin Therapy Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example DTP 463 D8 XXXXX Variants (all may be used) DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 463 Begin Therapy DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Begin Therapy Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 262 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP DATE - Certification Revision Recertification Date To specify any or all of a date, a time, or a time period Usage notes Required when CR301 (DMERC Certification) "R" or "S". If not required by this implementation guide, do not send. Example DTP 607 D8 XXXXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 607 Certification Revision DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Certification Revision or Recertification Date String (AN) Required Min 1 Max 35 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 263 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send. Example DTP 454 D8 X Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 264 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Last Certification Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF). Example DTP 461 D8 XXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 461 Last Certification DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Certification Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 265 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when a claim involves physician services for routine foot care; and is different than the date listed at the claim level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.; Example DTP 304 D8 XXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Treatment or Therapy Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 266 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example DTP 455 D8 XX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 267 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send. Example DTP 471 D8 XXXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 268 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and 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 first day of the drug used by the patient is 1 1 00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was 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 supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1 1 00. Example DTP 472 RD8 XXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 269 665 D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 270 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Shipped Date To specify any or all of a date, a time, or a time period Usage notes Required when billing or reporting shipped products. If not required by this implementation guide, do not send. Example DTP 011 D8 X Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 011 Shipped DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Shipped Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 271 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Test Date To specify any or all of a date, a time, or a time period Usage notes Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send. Example DTP 738 D8 XXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 738 Most Recent Hemoglobin or Hematocrit or Both 739 Most Recent Serum Creatine DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Test Performed Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 272 665 QTY 4600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop QTY Ambulance Patient Count To specify quantity information Usage notes Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. The QTY02 is the only place to report the number of patients when there are multiple patients transported. Example QTY PT 000000000000 Variants (all may be used) QTY Obstetric Anesthesia Additional Units Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity PT Patients QTY-02 380 Ambulance Patient Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 273 665 QTY 4600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop QTY Obstetric Anesthesia Additional Units To specify quantity information Usage notes Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time. If not required by this implementation guide, do not send. Example QTY FL 000000 Variants (all may be used) QTY Ambulance Patient Count Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity FL Units QTY-02 380 Obstetric Additional Units Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The number of additional units reported by an anesthesia provider to reflect additional complexity of services. 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 274 665 MEA 4620 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop MEA Test Result To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001) Usage notes Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results. OR Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier. If not required by this implementation guide, do not send. Example MEA TR R3 0000 Max use 5 Optional MEA-01 737 Measurement Reference Identification Code Identifier (ID) Required Code identifying the broad category to which a measurement applies OG Original Use OG to report Starting Dosage. TR Test Results MEA-02 738 Measurement Qualifier Identifier (ID) Required Code identifying a specific product or process characteristic to which a measurement applies HT Height R1 Hemoglobin R2 Hematocrit R3 Epoetin Starting Dosage R4 Creatinine MEA-03 739 Test Results Min 1 Max 15 Decimal number (R) Required The value of the measurement 1 30 25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 275 665 CN1 4650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet 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. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN1 02 000000 000000 XX 000000 XXXXX Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 276 665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 277 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9D X Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 278 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID- 2300). If not required by this implementation guide, do not send.; Example REF X4 XXXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 279 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Immunization Batch Number To specify identifying information Usage notes Required when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send. Example REF BT XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification BT Batch Number REF-02 127 Immunization Batch Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 280 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF 6R XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 281 665 receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 282 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send. Example REF EW XXXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 283 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Prior Authorization To specify identifying information Usage notes Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number. Example REF G1 XXXX 2U X Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization or Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 284 665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 285 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Referral Number To specify identifying information Usage notes Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number. Example REF 9F X 2U XXXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Referral Number reported in REF02 of this segment is for a non- destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 286 665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 287 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification To specify identifying information Usage notes Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send. Example REF F4 XXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F4 Facility Certification Number REF-02 127 Referring CLIA Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 288 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9B XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_7 |
9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Referral Number reported in REF02 of this segment is for a non- destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 286 665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 287 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification To specify identifying information Usage notes Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send. Example REF F4 XXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F4 Facility Certification Number REF-02 127 Referring CLIA Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 288 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9B XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 289 665 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Postage Claimed Amount To indicate the total monetary amount Usage notes Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send. When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount. Example AMT F4 000000000000000 Variants (all may be used) AMT Sales Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F4 Postage Claimed AMT-02 782 Postage Claimed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 290 665 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Sales Tax Amount To indicate the total monetary amount Usage notes Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount. Example AMT T 00000000 Variants (all may be used) AMT Postage Claimed Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount T Tax AMT-02 782 Sales Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 291 665 K3 4800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop K3 File Information To transmit a fixed-format record or matrix contents Usage notes 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. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3 XXXX Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 292 665 NTE 4850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop NTE Line Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description. Example NTE ADD XX Variants (all may be used) NTE Third Party Organization Notes Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information DCP Goals, Rehabilitation Potential, or Discharge Plans NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 293 665 NTE 4850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTE TPO X Variants (all may be used) NTE Line Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 294 665 PS1 4880 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop PS1 Purchased Service Information To specify the information about services that are purchased Usage notes Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source. OR Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses. If not required by this implementation guide, do not send. Example PS1 XX 0000 Max use 1 Optional PS1-01 127 Purchased Service Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PS101 is provider identification number. Usage notes This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109. PS1-02 782 Purchased Service Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PS102 is cost of the purchased service. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 295 665 HCP 4920 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop HCP Line Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example HCP 02 0 00000000000000 XXXXXX 000000000 XXX 0 W K XXX MJ 0000000 T6 4 6 If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 296 665 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. HCP-06 127 Repriced Approved Ambulatory Patient Group Code String (AN) Optional Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. HCP-07 782 Repriced Approved Ambulatory Patient Group Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount HCP07 is the approved DRG amount. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type source of the descriptive number used in Product Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 297 665 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP10 is the approved procedure code. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 298 665 The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 299 665 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop LIN Drug Identification To specify basic item identification data Usage notes Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN's. If not required by this implementation guide, do not send. Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400. Example LIN UK XXX Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) LIN02 through LIN31 provide for fifteen different product service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. Usage notes At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation. EN EAN UCC - 13 EO EAN UCC - 8 HI HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message N4 National Drug Code in 5-4-2 Format ON Customer Order Number UK GTIN 14-digit Data Structure UP UCC - 12 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 300 665 LIN-03 234 National Drug Code or Universal Product Number String (AN) Required Min 1 Max 48 Identifying number for a product or service 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 301 665 CTP 4940 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop CTP Drug Quantity To specify pricing information Example CTP 0000000000000 UN Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 302 665 2410 Drug Identification Loop end REF 4950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop REF Prescription or Compound Drug Association Number To specify identifying information Usage notes Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REF VY XXXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 303 665 2420A Rendering Provider Name Loop Max 1 Optional Usage notes You should only use 2420A when it is different than Loop 2310B NM1 82. Variants (all may be used) Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. OR Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID- 2010AA Billing Provider. If not required by this implementation guide, do not send.; Example NM1 82 1 XXXX XXXX XX X XX XXXXXX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 304 665 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 305 665 PRV 5050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop PRV Rendering Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRV PE PXC XX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 306 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXXX 2U XXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 307 665 2420A Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 308 665 2420B Purchased Service Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Purchased Service Provider Name Loop NM1 Purchased Service Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send. Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations. Example NM1 QB 1 XX XXXXXX If either Identification Code Qualifier (NM1-08) or Purchased Service Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. QB Purchase Service Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-08 66 Identification Code Qualifier Identifier (ID) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 309 665 Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Purchased Service Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 310 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Purchased Service Provider Name Loop REF Purchased Service Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 0B XXXXXX 2U XXXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Purchased Service Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 311 665 2420B Purchased Service Provider Name Loop end To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 312 665 2420C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.; Example NM1 77 2 XXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 313 665 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 314 665 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XX XXXXXX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 315 665 N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXXX XX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 316 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 317 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF G2 XXX 2U XXXXXX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 318 665 2420C Service Facility Location Name Loop end Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 319 665 2420D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Supervising Provider Name Loop NM1 Supervising Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send. Example NM1 DQ 1 XXXXX X XX XXX XX XXX If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Supervising Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 320 665 Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 321 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Supervising Provider Name Loop REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 0B XX 2U X Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 322 665 2420D Supervising Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 323 665 2420E Ordering Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop NM1 Ordering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send. Example NM1 DK 1 XXX X X XXXXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Ordering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. DK Ordering Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Ordering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 324 665 Individual last name or organizational name NM1-04 1036 Ordering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Ordering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Ordering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Ordering Provider Identifier | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_8 |
or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 322 665 2420D Supervising Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 323 665 2420E Ordering Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop NM1 Ordering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send. Example NM1 DK 1 XXX X X XXXXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Ordering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. DK Ordering Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Ordering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 324 665 Individual last name or organizational name NM1-04 1036 Ordering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Ordering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Ordering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Ordering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 325 665 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop N3 Ordering Provider Address To specify the location of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N3 XXXX XX Max use 1 Optional N3-01 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 326 665 N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop N4 Ordering Provider City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N4 XX XX XXX XX Only one of Ordering Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Ordering Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ordering Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ordering Provider Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 327 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 328 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop REF Ordering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF G2 XXXXXX 2U XXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Ordering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 329 665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 330 665 PER 5300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop PER Ordering Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC XXXXX EM XXXXXX EM XXX EM XX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Ordering Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 331 665 2420E Ordering Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 332 665 2420F Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed reported in this transaction. Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example NM1 P3 1 XX XXXXX XXXX XXXXX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 333 665 Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 334 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XX 2U XX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 335 665 2420F Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 336 665 2420G Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Pick-up Location Loop NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.; Example NM1 PW 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 337 665 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Pick-up Location Loop N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXXX XXXXX Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 338 665 N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Pick-up Location Loop N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXX XXX Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 339 665 2420G Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 340 665 2420H Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Drop-off Location Loop NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send. Example NM1 45 2 XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 341 665 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Drop-off Location Loop N3 Ambulance Drop-off Location Address To specify the location of the named party Usage notes If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 X XX Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 342 665 N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Drop-off Location Loop N4 Ambulance Drop-off Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXXX XX XXXXXXX XXX Only one of Ambulance Drop-off State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Drop-off City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Drop-off State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Drop-off Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 343 665 2420H Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 344 665 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD XXXXXXX 0000000000 ER XXXX XX XX XX XX XXXX 0000000000000 00000 Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 345 665 Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 346 665 C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled or Unbundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 347 665 CAS 5450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS CO XXXXX 00000 000000000000000 XXXXX 00000000 00 000000000 XXXXX 0000 000000 XXXX 000 000000000 00 X 00000000 00 X 00000000 0 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 348 665 CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 349 665 CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 350 665 Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 351 665 DTP 5500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP 573 D8 XXXX Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 352 665 2430 Line Adjudication Information Loop end AMT 5505 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 353 665 2440 Form Identification Code Loop Max 1 Optional LQ 5510 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Form Identification Code Loop LQ Form Identification Code To identify standard industry codes Usage notes Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send. Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01 UT which identifies the form as a Medicare DMERC CMN form. LQ02 01.02 identifies which DMERC CMN form is being used. An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services. Example LQ UT XXXXXX Max use 1 Required LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list AS Form Type Code Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02. UT Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms LQ-02 1271 Form Identifier Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 354 665 FRM 5520 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Form Identification Code Loop FRM Supporting Documentation To specify information in response to a codified questionnaire document Usage notes The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes No questions, FRM03 for text uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQUT08.02 ). Example FRM XXXX N XXX 20250130 000 At least one of Question Response (FRM-02), Question Response (FRM-03), Question Response (FRM-04) or Question Response (FRM-05) is required Max use 99 Required FRM-01 350 Question Number Letter Min 1 Max 20 String (AN) Required Alphanumeric characters assigned for differentiation within a transaction set FRM01 is the question number on a questionnaire or codified form. FRM-02 1073 Question Response Identifier (ID) Optional Code indicating a Yes or No condition or response FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01. N No W Not Applicable Y Yes FRM-03 127 Question Response Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier FRM-04 373 Question Response CCYYMMDD format Date (DT) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 355 665 2440 Form Identification Code Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year FRM-05 332 Question Response Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 356 665 2000C Patient Hierarchical Level Loop Max 1 Optional HL 0010 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 3 2 23 0 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 23 Dependent HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 357 665 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 358 665 PAT 0070 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop PAT Patient Information To supply patient information Example PAT 53 D8 XXXX 01 000000 Y If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required Max use 1 Required PAT-01 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities Usage notes Specifies the patient's relationship to the person insured. 01 Spouse 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship PAT-05 1250 Date Time Period Format Qualifier Identifier (ID) Optional Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD PAT-06 1251 Patient Death Date Min 1 Max 35 String (AN) Optional Expression of a date, a time, or range of dates, times or dates and times PAT06 is the date of death. PAT-07 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken 01 Actual Pounds PAT-08 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 359 665 Numeric value of weight PAT08 is the patient's weight. PAT-09 1073 Pregnancy Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 360 665 2010CA Patient Name Loop Max 1 Required NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop NM1 Patient Name To supply the full name of an individual or organizational entity Example NM1 QC 1 XX XX X XXXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_9 |
there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 357 665 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 358 665 PAT 0070 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop PAT Patient Information To supply patient information Example PAT 53 D8 XXXX 01 000000 Y If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required Max use 1 Required PAT-01 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities Usage notes Specifies the patient's relationship to the person insured. 01 Spouse 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship PAT-05 1250 Date Time Period Format Qualifier Identifier (ID) Optional Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD PAT-06 1251 Patient Death Date Min 1 Max 35 String (AN) Optional Expression of a date, a time, or range of dates, times or dates and times PAT06 is the date of death. PAT-07 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken 01 Actual Pounds PAT-08 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 359 665 Numeric value of weight PAT08 is the patient's weight. PAT-09 1073 Pregnancy Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 360 665 2010CA Patient Name Loop Max 1 Required NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop NM1 Patient Name To supply the full name of an individual or organizational entity Example NM1 QC 1 XX XX X XXXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 361 665 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop N3 Patient Address To specify the location of the named party Example N3 XXXXXX XX Max use 1 Required N3-01 166 Patient Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Patient Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 362 665 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop N4 Patient City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXX XX XXXXX XX Only one of Patient State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Patient City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Patient State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Patient Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 363 665 DMG 0320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop DMG Patient Demographic Information To supply demographic information Example DMG D8 XXXXXX M Max use 1 Required DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Patient Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Patient Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 364 665 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop REF Property and Casualty Claim Number To specify identifying information Usage notes Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Example REF Y4 XX Variants (all may be used) REF Property and Casualty Patient Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 365 665 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop REF Property and Casualty Patient Identifier To specify identifying information Usage notes Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send. Example REF SY XXXXX Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1W Member Identification Number This code designates a patient identification number used by the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Property and Casualty Patient Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 366 665 PER 0400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop PER Property and Casualty Patient Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is different than the information provided in the Subscriber Contact Information PER segment in Loop ID- 2010BA and this information is deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC X TE XXXXXX EX XXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 367 665 2010CA Patient Name Loop end Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 368 665 2300 Claim Information Loop Max 100 Required CLM 1300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. 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 hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLM XX 00 X B X Y B N Y P EM XX XX XXX 02 3 Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is 20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 369 665 CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim. CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Place of Service Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. B Place of Service Codes for Professional or Dental Services C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-06 1073 Provider or Supplier Signature Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file. N No Y Yes CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 370 665 Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-10 1351 Patient Signature Source Code Identifier (ID) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 371 665 Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. CLM-11 C024 Related Causes Information To identify one or more related causes and associated state or country information Usage notes Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send. Max use 1 Optional C024-01 1362 Related Causes Code Identifier (ID) Required Code identifying an accompanying cause of an illness, injury or an accident AA Auto Accident EM Employment OA Other Accident C024-02 1362 Related Causes Code Min 2 Max 3 Identifier (ID) Optional Code identifying an accompanying cause of an illness, injury or an accident C024-04 156 Auto Accident State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA". C024-05 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country CLM-12 1366 Special Program Indicator Identifier (ID) Optional Code indicating the Special Program under which the services rendered to the patient were performed 02 Physically Handicapped Children's Program This code is used for Medicaid claims only. 03 Special Federal Funding This code is used for Medicaid claims only. 05 Disability 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 372 665 This code is used for Medicaid claims only. 09 Second Opinion or Surgery This code is used for Medicaid claims only. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 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 Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 373 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Accident To specify any or all of a date, a time, or a time period Usage notes Required when CLM11-1 or CLM11-2 has a value of AA' or OA'. OR Required when CLM11-1 or CLM11-2 has a value of EM' and this claim is the result of an accident. If not required by this implementation guide, do not send. Example DTP 439 D8 XXXXX Variants (all may be used) DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 439 Accident DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Accident Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 374 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 375 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Acute Manifestation To specify any or all of a date, a time, or a time period Usage notes Required when Loop ID-2300 CR208 "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send. Example DTP 453 D8 X Variants (all may be used) DTP Date - Accident DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 453 Acute Manifestation of a Chronic Condition DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Acute Manifestation Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 376 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 377 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Admission To specify any or all of a date, a time, or a time period Usage notes Required on all ambulance claims when the patient was known to be admitted to the hospital. OR Required on all claims involving inpatient medical visits. If not required by this implementation guide, do not send. Example DTP 435 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Admission Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 378 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 379 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Assumed and Relinquished Care Dates To specify any or all of a date, a time, or a time period Usage notes Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send. Assumed Care Date is the date care was assumed by another provider during post- operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A". Example DTP 091 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 090 Report Start Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care. 091 Report End Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 380 665 DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Assumed or Relinquished Care Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 381 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Authorized Return to Work To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP 296 D8 XX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 296 Initial Disability Period Return To Work This is the date the provider has authorized the patient to return to work. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Work Return Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 382 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 383 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Disability Dates To specify any or all of a date, a time, or a time period Usage notes Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his her work. OR Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor. If not required by this implementation guide, do not send. Example DTP 360 RD8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 314 Disability Use code 314 when both disability start and end date are being reported. 360 Initial Disability Period Start Use code 360 if patient is currently disabled and disability end date is unknown. 361 Initial Disability Period End Use code 361 if patient is no longer disabled and the start date is unknown. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 384 665 Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD Use code D8 when DTP01 is 360 or 361. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use code RD8 when DTP01 is 314. DTP-03 1251 Disability From Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 385 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Discharge To specify any or all of a date, a time, or a time period Usage notes Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send. Example DTP 096 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Discharge Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 386 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 387 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Hearing and Vision Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send. Example DTP 471 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 388 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 389 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 454 D8 XX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 390 665 DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 391 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Last Menstrual Period To specify any or all of a date, a time, or a time period Usage notes Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send. Example DTP 484 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 484 Last Menstrual Period DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Menstrual Period Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 392 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 393 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 304 D8 XX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 394 665 D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Seen Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 395 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Last Worked To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP 297 D8 XXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 297 Initial Disability Period Last Day Worked DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Worked Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 396 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 397 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 455 D8 X Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required 1 | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_10 |
- Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 297 Initial Disability Period Last Day Worked DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Worked Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 396 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 397 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 455 D8 X Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 398 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 399 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Onset of Current Illness or Symptom To specify any or all of a date, a time, or a time period Usage notes Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send. This date is the onset of acute symptoms for the current illness or condition. Example DTP 431 D8 X Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 431 Onset of Current Symptoms or Illness DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Onset of Current Illness or Injury Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 400 665 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 401 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Property and Casualty Date of First Contact To specify any or all of a date, a time, or a time period Usage notes Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send. This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date. Example DTP 444 D8 XXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 444 First Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Date Time Period Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 402 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 403 665 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP 050 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 404 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 405 665 PWK 1550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK DJ EM AC XX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 406 665 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 407 665 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 408 665 CN1 1600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet 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. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN1 02 00 000000 XXX 000 XXX Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 409 665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 410 665 AMT 1750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop AMT Patient Amount Paid To indicate the total monetary amount Usage notes Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s). Example AMT F5 0 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F5 Patient Amount Paid AMT-02 782 Patient Amount Paid Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 411 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF 9C XXXXX Variants (all may be used) REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 412 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Care Plan Oversight To specify identifying information Usage notes Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send. This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished. Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number. On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI. Example REF 1J XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1J Facility ID Number REF-02 127 Care Plan Oversight Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 413 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REF D9 XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 414 665 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 415 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line. In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400. Example REF X4 XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number String (AN) Required Min 1 Max 50 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 416 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 417 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF P4 XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 418 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REF LX XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 419 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send. Example REF EW XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 420 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Mandatory Medicare (Section 4081) Crossover Indicator To specify identifying information Usage notes Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send. Example REF F5 XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F5 Medicare Version Code REF-02 127 Medicare Section 4081 Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The allowed values for this element are: Y 4081 N Regular crossover 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 421 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REF EA X Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 422 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF F8 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 423 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF G1 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 424 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 425 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF 9F X Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 426 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 427 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF 9A X Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 428 665 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF 4N XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Allowable values for this element are: 1 Immediate Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 429 665 6 Request for Override Pending 7 Special Handling 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 430 665 K3 1850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop K3 File Information To transmit a fixed-format record or matrix contents Usage notes 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. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3 XXX Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 431 665 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTE TPO XXXXX Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information CER Certification Narrative DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description TPO Third Party Organization Notes NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 432 665 CR1 1950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send. The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101. Example CR1 LB 000000 A DH 0 XXXX X If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both Can be used to indicate that the patient was transferred to a residential facility. B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 433 665 Numeric value of quantity CR106 is the distance traveled during transport. Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 434 665 CR2 2000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CR2 Spinal Manipulation Service Information To supply information related to the chiropractic service rendered to a patient Usage notes Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. Example CR2 F X XXXXX Max use 1 Optional CR2-08 1342 Patient Condition Code Identifier (ID) Required Code indicating the nature of a patient's condition A Acute Condition C Chronic Condition D Non-acute E Non-Life Threatening F Routine G Symptomatic M Acute Manifestation of a Chronic Condition CR2-10 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR210 is a description of the patient's condition. CR2-11 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR211 is an additional description of the patient's condition. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 435 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CRC Ambulance Certification To supply information on conditions Usage notes Required when the claim involves ambulance transport services AND when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send. The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01. Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07. Example CRC 07 N 05 XX XX XXX XXX Variants (all may be used) CRC EPSDT Referral CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 436 665 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 437 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_11 |
to clarify the related data elements and their content CR211 is an additional description of the patient's condition. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 435 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CRC Ambulance Certification To supply information on conditions Usage notes Required when the claim involves ambulance transport services AND when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send. The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01. Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07. Example CRC 07 N 05 XX XX XXX XXX Variants (all may be used) CRC EPSDT Referral CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 436 665 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 437 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CRC EPSDT Referral To supply information on conditions Usage notes Required on Early Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRC ZZ Y AV XXX XXX Variants (all may be used) CRC Ambulance Certification CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 438 665 NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 439 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CRC Homebound Indicator To supply information on conditions Usage notes Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send. Example CRC 75 Y IH Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 75 Functional Limitations CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Y Yes CRC-03 1321 Homebound Indicator Identifier (ID) Required Code indicating a condition IH Independent at Home 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 440 665 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CRC Patient Condition Information: Vision To supply information on conditions Usage notes Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send. Example CRC E2 N L2 XX XX XXX XX Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Homebound Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. E1 Spectacle Lenses E2 Contact Lenses E3 Spectacle Frames CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition L1 General Standard of 20 Degree or.5 Diopter Sphere or Cylinder Change Met L2 Replacement Due to Loss or Theft L3 Replacement Due to Breakage or Damage L4 Replacement Due to Patient Preference L5 Replacement Due to Medical Reason CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 441 665 Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 442 665 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Anesthesia Related Procedure To supply information related to the delivery of health care Usage notes Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code. If not required by this implementation guide, do not send. Example HI BP XXXXX BO XXXXX Variants (all may be used) HI Condition Information HI Health Care Diagnosis Code Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BP Health Care Financing Administration Common Procedural Coding System Principal Procedure C022-02 1271 Anesthesia Related Surgical Procedure String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 443 665 BO Health Care Financing Administration Common Procedural Coding System C022-02 1271 Industry Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 444 665 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Condition Information To supply information related to the delivery of health care Usage notes Required when condition information applies to the claim. If not required by this implementation guide, do not send. Example HI BG XXXXX BG XX BG X BG XXXXX BG XXXXX BG XXXXX X BG XXXXX BG XXXXXX BG XXXXXX BG XX BG XXX BG XX XXXX Variants (all may be used) HI Anesthesia Related Procedure HI Health Care Diagnosis Code Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 445 665 BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 446 665 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 447 665 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 448 665 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 449 665 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 450 665 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HI Health Care Diagnosis Code To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BK XXXXXX ABF XXX ABF XXX BF XX BF X BF XXXXX X ABF XXXX BF XX ABF X ABF XXXX BF XX BF XXXXX Variants (all may be used) HI Anesthesia Related Procedure HI Condition Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 451 665 C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 452 665 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 453 665 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 454 665 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis ICD-9 Codes C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 455 665 OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 456 665 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 457 665 HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 458 665 HCP 2410 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop HCP Claim Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 14 0000000000000 000000000000 XXXXXX 00 X 000 00000000 T3 1 6 Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 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 Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 459 665 HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved Ambulatory Patient Group Code String (AN) Optional Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Ambulatory Patient Group Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount HCP07 is the approved DRG amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-13 901 Reject Reason Code Identifier (ID) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 460 665 Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 461 665 2310A Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required when this claim involves a referral. If not required by this implementation guide, do not send. When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed reported in this transaction. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 DN 1 XXXXXX XXXX XXXX XXXXXX XX XXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 462 665 NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 463 665 2310A Referring Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF G2 XX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 464 665 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, do not send. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 82 2 XXXXXX X XXXXXX XXXXX XX XX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 465 665 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_12 |
mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF G2 XX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 464 665 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, do not send. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 82 2 XXXXXX X XXXXXX XXXXX XX XX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 465 665 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 466 665 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop PRV Rendering Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01. Example PRV PE PXC XXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 467 665 2310B Rendering Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 1G XXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 468 665 2310C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 77 2 XXXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 469 665 NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 470 665 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXXXXX XXXXXX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 471 665 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXXXXX XXX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 472 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 473 665 REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 0B X Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 474 665 PER 2750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop PER Service Facility Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is different than the information provided in Loop ID-1000A Submitter EDI Contact Information PER Segment, and Loop ID-2010AA Billing Provider Contact Information PER segment and when deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC XX TE XX EX XXXXXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 475 665 2310C Service Facility Location Name Loop end PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 476 665 2310D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Supervising Provider Name Loop NM1 Supervising Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 DQ 1 XXXXX XXXXXX XXXXX XXXXXX XX XXX If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Supervising Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 477 665 Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 478 665 2310D Supervising Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Supervising Provider Name Loop REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF 1G XXXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 479 665 2310E Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Ambulance Pick-up Location Loop NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 PW 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 480 665 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Ambulance Pick-up Location Loop N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXXXX XXXXX Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 481 665 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Ambulance Pick-up Location Loop N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXXXX XXX Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 482 665 2310E Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 483 665 2310F Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Ambulance Drop-off Location Loop NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 45 2 X Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 484 665 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Ambulance Drop-off Location Loop N3 Ambulance Drop-off Location Address To specify the location of the named party Example N3 XX XXXXXX Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 485 665 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Ambulance Drop-off Location Loop N4 Ambulance Drop-off Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXXX XX XXXX XXX Only one of Ambulance Drop-off State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Drop-off City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Drop-off State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Drop-off Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 486 665 2310F Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 487 665 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR C 01 XXXXXX XX 42 MC Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. 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 This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 488 665 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 489 665 16 Health Maintenance Organization (HMO) Medicare Risk 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 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 490 665 CAS 2950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS PI X 0000000000000 0000 XX 00000000000000 0 0 XXXX 0000 000000 XXXXX 00 00000 XXX 000000000 000000 000 XXXXX 000000000000000 0000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 491 665 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 492 665 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 493 665 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 494 665 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT D 000000000000 Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 495 665 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT A8 000000000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 496 665 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 000000000000000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 497 665 OI 3100 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI W P Y Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes OI-04 1351 Patient Signature Source Code Identifier (ID) Optional Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider Usage notes This is a crosswalk from CLM10 when doing COB. P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 498 665 Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 499 665 MOA 3200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA 000000 0000000000 XX XXXXX X XXXXX XXXXX 0000 0000 000000000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 500 665 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 501 665 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 IL 2 XX X XXXXXX XXXXXX MI XXXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_13 |
as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 500 665 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 501 665 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 IL 2 XX X XXXXXX XXXXXX MI XXXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 502 665 Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 503 665 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3 XXXX X Max use 1 Optional N3-01 166 Other Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 504 665 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4 XXXXXXX XX XXXXXX XX Only one of Other Subscriber State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Subscriber State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 505 665 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 506 665 2330A Other Subscriber Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY XX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 507 665 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 PR 2 X XV XXXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 508 665 (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 509 665 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N3 Other Payer Address To specify the location of the named party Usage notes 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. Example N3 XXX XXXXX Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 510 665 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XXXXXXX XX XXXX XX Only one of Other Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 511 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 512 665 DTP 3450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP 573 D8 XXXX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 513 665 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REF T4 XXXXX Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The only valid value for this element is Y'. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 514 665 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REF F8 XXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 515 665 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REF G1 XXXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 516 665 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF 9F XXXXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 517 665 2330B Other Payer Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF EI XXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 518 665 2330C Other Payer Referring Provider Loop Max 2 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Referring Provider Loop NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 DN 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 519 665 1 Person 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 520 665 2330C Other Payer Referring Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Referring Provider Loop REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF 0B XXXXXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 521 665 2330D Other Payer Rendering Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Rendering Provider Loop NM1 Other Payer Rendering Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 82 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 522 665 1 Person 2 Non-Person Entity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 523 665 2330D Other Payer Rendering Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Rendering Provider Loop REF Other Payer Rendering Provider Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU XX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Rendering Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 524 665 2330E Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 77 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 525 665 2330E Other Payer Service Facility Location Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop REF Other Payer Service Facility Location Secondary Identification To specify identifying information Example REF 0B XXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 526 665 2330F Other Payer Supervising Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Supervising Provider Loop NM1 Other Payer Supervising Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 DQ 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 527 665 2330F Other Payer Supervising Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Supervising Provider Loop REF Other Payer Supervising Provider Secondary Identification To specify identifying information Example REF LU XXXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Supervising Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 528 665 2330G Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Billing Provider Loop NM1 Other Payer Billing Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 85 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 529 665 1 Person 2 Non-Person Entity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 530 665 2330G Other Payer Billing Provider Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Billing Provider Loop REF Other Payer Billing Provider Secondary Identification To specify identifying information Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF G2 XXXX Max use 2 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Billing Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 531 665 2400 Service Line Number Loop Max 50 Required LX 3650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX 00 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 532 665 SV1 3700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV1 Professional Service To specify the service line item detail for a health care professional Example SV1 ER XXXXX XX XX XX XX XXXXX 00000 MJ 000000 X 0 0 00 00 Y Y Y 0 Max use 1 Required SV1-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting or adjudication processes. The NDC number is reported in the LIN segment of Loop ID- 2410 only. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 533 665 By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV1-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 534 665 Monetary amount SV102 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and or postage claimed amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV1-03 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes Required for Anesthesia claims. Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre- anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel. UN Unit SV1-04 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV1-05 1331 Place of Service Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. SV105 is the place of service. Usage notes See CODE SOURCE 237: Place of Service Codes for Professional Claims SV1-07 C004 Composite Diagnosis Code Pointer To identify one or more diagnosis code pointers Max use 1 Required C004-01 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 535 665 A pointer to the diagnosis code in the order of importance to this service C004-01 identifies the primary diagnosis code for this service line. Usage notes This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300. C004-02 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-02 identifies the second diagnosis code for this service line. C004-03 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-03 identifies the third diagnosis code for this service line. C004-04 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-04 identifies the fourth diagnosis code for this service line. SV1-09 1073 Emergency Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related. Usage notes For this implementation, the listed value takes precedence over the semantic note. Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Y Yes SV1-11 1073 EPSDT Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 536 665 When this element is used, this service is not the screening service. Y Yes SV1-12 1073 Family Planning Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes SV1-15 1327 Co-Pay Status Code Identifier (ID) Optional Code indicating whether or not co-payment requirements were met on a line by line basis 0 Copay exempt 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 537 665 SV5 4000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV5 Durable Medical Equipment Service To specify the claim service detail for durable medical equipment Usage notes Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send. Example SV5 HC XXXX DA 0000000000000 0000 0000000000 6 Max use 1 Optional SV5-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Procedure Identifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This value must be the same as that reported in SV101-2. SV5-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days SV5-03 380 Length of Medical Necessity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 538 665 | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_14 |
1073 EPSDT Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 536 665 When this element is used, this service is not the screening service. Y Yes SV1-12 1073 Family Planning Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes SV1-15 1327 Co-Pay Status Code Identifier (ID) Optional Code indicating whether or not co-payment requirements were met on a line by line basis 0 Copay exempt 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 537 665 SV5 4000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV5 Durable Medical Equipment Service To specify the claim service detail for durable medical equipment Usage notes Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send. Example SV5 HC XXXX DA 0000000000000 0000 0000000000 6 Max use 1 Optional SV5-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Procedure Identifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This value must be the same as that reported in SV101-2. SV5-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days SV5-03 380 Length of Medical Necessity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 538 665 SV503 is the length of medical treatment required. SV5-04 782 DME Rental Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV504 is the rental price. SV5-05 782 DME Purchase Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV505 is the purchase price. SV5-06 594 Rental Unit Price Indicator Identifier (ID) Required Code indicating frequency or type of activities or actions being reported SV506 is the frequency at which the rental equipment is billed. 1 Weekly 4 Monthly 6 Daily 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 539 665 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Durable Medical Equipment Certificate of Medical Necessity Indicator To identify the type or transmission or both of paperwork or supporting information Usage notes Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.; Example PWK CT AB Variants (all may be used) PWK Line Supplemental Information Max use 1 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item CT Certification PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AB Previously Submitted to Payer AD Certification Included in this Claim AF Narrative Segment Included in this Claim AG No Documentation is Required NS Not Specified NS Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 540 665 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK 15 FT AC XXXX Variants (all may be used) PWK Durable Medical Equipment Certificate of Medical Necessity Indicator If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 541 665 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AA Available on Request at Provider Site 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 542 665 This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 543 665 CR1 4250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CR1 LB 00000000 E DH 00000000 XX XXXX If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CR106 is the distance traveled during transport. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 544 665 Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 545 665 CR3 4350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop CR3 Durable Medical Equipment Certification To supply information regarding a physician's certification for durable medical equipment Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example CR3 S MO 00000000000000 Max use 1 Optional CR3-01 1322 Certification Type Code Identifier (ID) Required Code indicating the type of certification I Initial R Renewal S Revised CR3-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken CR302 and CR303 specify the time period covered by this certification. MO Months CR3-03 380 Durable Medical Equipment Duration Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Length of time DME equipment is needed. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 546 665 CRC 4500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop CRC Ambulance Certification To supply information on conditions Usage notes The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CRC 07 N 05 XX XX XX XX Variants (all may be used) CRC Condition Indicator Durable Medical Equipment CRC Hospice Employee Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 547 665 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 548 665 CRC 4500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop CRC Condition Indicator Durable Medical Equipment To supply information on conditions Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The first example shows a case where an item billed was not a replacement item. Example CRC 09 N ZV XX Variants (all may be used) CRC Ambulance Certification CRC Hospice Employee Indicator Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 09 Durable Medical Equipment Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 38 Certification signed by the physician is on file at the supplier's office ZV Replacement Item CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 549 665 Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 550 665 CRC 4500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop CRC Hospice Employee Indicator To supply information on conditions Usage notes Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The example shows the method used to indicate whether the rendering provider is an employee of the hospice. Example CRC 70 N 65 Variants (all may be used) CRC Ambulance Certification CRC Condition Indicator Durable Medical Equipment Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 70 Hospice CRC-02 1073 Hospice Employed Provider Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes A "Y" value indicates the provider is employed by the hospice. A "N" value indicates the provider is not employed by the hospice. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 551 665 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 552 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Begin Therapy Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example DTP 463 D8 XXXX Variants (all may be used) DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 463 Begin Therapy DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Begin Therapy Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 553 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP DATE - Certification Revision Recertification Date To specify any or all of a date, a time, or a time period Usage notes Required when CR301 (DMERC Certification) "R" or "S". If not required by this implementation guide, do not send. Example DTP 607 D8 X Variants (all may be used) DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 607 Certification Revision DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Certification Revision or Recertification Date String (AN) Required Min 1 Max 35 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 554 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send. Example DTP 454 D8 XX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 555 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Last Certification Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF). Example DTP 461 D8 X Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 461 Last Certification DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Certification Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 556 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when a claim involves physician services for routine foot care; and is different than the date listed at the claim level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.; Example DTP 304 D8 XXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Treatment or Therapy Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 557 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example DTP 455 D8 XXXXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 558 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send. Example DTP 471 D8 XXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 559 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and 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 first day of the drug used by the patient is 1 1 00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was 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 supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1 1 00. Example DTP 472 RD8 XXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 560 665 D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 561 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Shipped Date To specify any or all of a date, a time, or a time period Usage notes Required when billing or reporting shipped products. If not required by this implementation guide, do not send. Example DTP 011 D8 XXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 011 Shipped DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Shipped Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 562 665 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Test Date To specify any or all of a date, a time, or a time period Usage notes Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send. Example DTP 738 D8 XX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 738 Most Recent Hemoglobin or Hematocrit or Both 739 Most Recent Serum Creatine DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Test Performed Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 563 665 QTY 4600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop QTY Ambulance Patient Count To specify quantity information Usage notes Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. The QTY02 is the only place to report the number of patients when there are multiple patients transported. Example QTY PT 0000000000 Variants (all may be used) QTY Obstetric Anesthesia Additional Units Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity PT Patients QTY-02 380 Ambulance Patient Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 564 665 QTY 4600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop QTY Obstetric Anesthesia Additional Units To specify quantity information Usage notes Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time. If not required by this implementation guide, do not send. Example QTY FL 000000000000000 Variants (all may be used) QTY Ambulance Patient Count Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity FL Units QTY-02 380 Obstetric Additional Units Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The number of additional units reported by an anesthesia provider to reflect additional complexity of services. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 565 665 MEA 4620 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop MEA Test Result To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001) Usage notes Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results. OR Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier. If not required by this implementation guide, do not send. Example MEA OG R1 00000000000 Max use 5 Optional MEA-01 737 Measurement Reference Identification Code Identifier (ID) Required Code identifying the broad category to which a measurement applies OG Original Use OG to report Starting Dosage. TR Test Results MEA-02 738 Measurement Qualifier Identifier (ID) Required Code identifying a specific product or process characteristic to which a measurement applies HT Height R1 Hemoglobin R2 Hematocrit R3 Epoetin Starting Dosage R4 Creatinine MEA-03 739 Test Results Min 1 Max 15 Decimal number (R) Required The value of the measurement 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 566 665 CN1 4650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet 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. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN1 05 00000000000000 0000 XXX 00000 XXXX Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 567 665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 568 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9D XXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 569 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID- 2300). If not required by this implementation guide, do not send.; Example REF X4 XXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 570 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Immunization Batch Number To specify identifying information Usage notes Required when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send. Example REF BT X Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification BT Batch Number REF-02 127 Immunization Batch Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 571 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF 6R XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 572 665 receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_15 |
when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send. Example REF BT X Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification BT Batch Number REF-02 127 Immunization Batch Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 571 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF 6R XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 572 665 receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 573 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send. Example REF EW XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 574 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Prior Authorization To specify identifying information Usage notes Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number. Example REF G1 XXXXXX 2U XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization or Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 575 665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 576 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Referral Number To specify identifying information Usage notes Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number. Example REF 9F X 2U XXXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Referral Number reported in REF02 of this segment is for a non- destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 577 665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 578 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification To specify identifying information Usage notes Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send. Example REF F4 XXXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F4 Facility Certification Number REF-02 127 Referring CLIA Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 579 665 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9B XXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 580 665 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Postage Claimed Amount To indicate the total monetary amount Usage notes Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send. When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount. Example AMT F4 000000000000 Variants (all may be used) AMT Sales Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F4 Postage Claimed AMT-02 782 Postage Claimed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 581 665 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Sales Tax Amount To indicate the total monetary amount Usage notes Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount. Example AMT T 0000000000 Variants (all may be used) AMT Postage Claimed Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount T Tax AMT-02 782 Sales Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 582 665 K3 4800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop K3 File Information To transmit a fixed-format record or matrix contents Usage notes 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. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3 XXX Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 583 665 NTE 4850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop NTE Line Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description. Example NTE ADD XX Variants (all may be used) NTE Third Party Organization Notes Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information DCP Goals, Rehabilitation Potential, or Discharge Plans NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 584 665 NTE 4850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTE TPO XXX Variants (all may be used) NTE Line Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 585 665 PS1 4880 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop PS1 Purchased Service Information To specify the information about services that are purchased Usage notes Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source. OR Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses. If not required by this implementation guide, do not send. Example PS1 XXXXXX 00000000000000 Max use 1 Optional PS1-01 127 Purchased Service Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PS101 is provider identification number. Usage notes This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109. PS1-02 782 Purchased Service Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PS102 is cost of the purchased service. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 586 665 HCP 4920 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop HCP Line Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example HCP 01 00 00000000 XXX 00000000 X 00000000000 W K X MJ 000 T5 2 6 If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 587 665 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. HCP-06 127 Repriced Approved Ambulatory Patient Group Code String (AN) Optional Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. HCP-07 782 Repriced Approved Ambulatory Patient Group Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount HCP07 is the approved DRG amount. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type source of the descriptive number used in Product Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 588 665 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP10 is the approved procedure code. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 589 665 The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 590 665 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop LIN Drug Identification To specify basic item identification data Usage notes Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN's. If not required by this implementation guide, do not send. Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400. Example LIN UK XXXXXX Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) LIN02 through LIN31 provide for fifteen different product service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. Usage notes At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation. EN EAN UCC - 13 EO EAN UCC - 8 HI HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message N4 National Drug Code in 5-4-2 Format ON Customer Order Number UK GTIN 14-digit Data Structure UP UCC - 12 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 591 665 LIN-03 234 National Drug Code or Universal Product Number String (AN) Required Min 1 Max 48 Identifying number for a product or service 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 592 665 CTP 4940 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop CTP Drug Quantity To specify pricing information Example CTP 000000 ML Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 593 665 2410 Drug Identification Loop end REF 4950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop REF Prescription or Compound Drug Association Number To specify identifying information Usage notes Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REF VY X Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 594 665 2420A Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. OR Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID- 2010AA Billing Provider. If not required by this implementation guide, do not send.; Example NM1 82 2 XX XX XXXX XXX XX XX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 595 665 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 596 665 PRV 5050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop PRV Rendering Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRV PE PXC XXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 597 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF G2 XXXXXX 2U XXXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 598 665 2420A Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 599 665 2420B Purchased Service Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Purchased Service Provider Name Loop NM1 Purchased Service Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send. Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations. Example NM1 QB 1 XX XX If either Identification Code Qualifier (NM1-08) or Purchased Service Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. QB Purchase Service Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-08 66 Identification Code Qualifier Identifier (ID) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 600 665 Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Purchased Service Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 601 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Purchased Service Provider Name Loop REF Purchased Service Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXX 2U X Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Purchased Service Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 602 665 2420B Purchased Service Provider Name Loop end Required when the identifier reported in REF02 of this segment is for a non-destination payer. C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 603 665 2420C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.; Example NM1 77 2 X XX XXXXX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 604 665 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 605 665 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXXXXX XXX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 606 665 N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXX XX XXXX XXX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 607 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 608 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF LU X 2U XXXXXX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_16 |
XXX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 607 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 608 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF LU X 2U XXXXXX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 609 665 2420C Service Facility Location Name Loop end Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 610 665 2420D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Supervising Provider Name Loop NM1 Supervising Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send. Example NM1 DQ 1 XXXXXX XXXX XXX XXXXXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Supervising Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 611 665 Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 612 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Supervising Provider Name Loop REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 0B XXX 2U X Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 613 665 2420D Supervising Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 614 665 2420E Ordering Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop NM1 Ordering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send. Example NM1 DK 1 X XXXXX XX XXX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Ordering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. DK Ordering Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Ordering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 615 665 Individual last name or organizational name NM1-04 1036 Ordering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Ordering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Ordering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Ordering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 616 665 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop N3 Ordering Provider Address To specify the location of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N3 XXXXXX XX Max use 1 Optional N3-01 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 617 665 N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop N4 Ordering Provider City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N4 XXXXXX XX XXXXX XXX Only one of Ordering Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Ordering Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ordering Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ordering Provider Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 618 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 619 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop REF Ordering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF G2 XXXXXX 2U X Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Ordering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 620 665 C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 621 665 PER 5300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop PER Ordering Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC XXXX FX X FX XXX FX X If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Ordering Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 622 665 2420E Ordering Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 623 665 2420F Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed reported in this transaction. Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example NM1 P3 1 XXX XXXXX XXXXX X XX XXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 624 665 NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 625 665 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF G2 X 2U XXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 626 665 2420F Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 627 665 2420G Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Pick-up Location Loop NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.; Example NM1 PW 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 628 665 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Pick-up Location Loop N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXX XX Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 629 665 N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Pick-up Location Loop N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXXX XX XXXXXXX XXX Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 630 665 2420G Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 631 665 2420H Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Drop-off Location Loop NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send. Example NM1 45 2 XXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 632 665 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Drop-off Location Loop N3 Ambulance Drop-off Location Address To specify the location of the named party Usage notes If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXXX XXXX Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 633 665 N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Drop-off Location Loop N4 Ambulance Drop-off Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXX XX XXX XX Only one of Ambulance Drop-off State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Drop-off City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Drop-off State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Drop-off Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 634 665 2420H Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 635 665 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD XXXXXX 00 ER X XX XX XX XX XXX 000 0000 Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 636 665 Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 637 665 C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled or Unbundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 638 665 CAS 5450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS OA XXXX 00000 000000000000 XX 000000000 0 XXX X 000000000000000 00 X 0000000000000 00000000 XX X 000000000 00 XXX 00000000 000000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 639 665 CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 640 665 CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 641 665 Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 642 665 DTP 5500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP 573 D8 X Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 643 665 2430 Line Adjudication Information Loop end AMT 5505 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 644 665 2440 Form Identification Code Loop Max 1 Optional LQ 5510 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Form Identification Code Loop LQ Form Identification Code To identify standard industry codes Usage notes Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send. Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_17 |
health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 642 665 DTP 5500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP 573 D8 X Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 643 665 2430 Line Adjudication Information Loop end AMT 5505 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 644 665 2440 Form Identification Code Loop Max 1 Optional LQ 5510 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Form Identification Code Loop LQ Form Identification Code To identify standard industry codes Usage notes Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send. Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01 UT which identifies the form as a Medicare DMERC CMN form. LQ02 01.02 identifies which DMERC CMN form is being used. An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services. Example LQ AS X Max use 1 Required LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list AS Form Type Code Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02. UT Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms LQ-02 1271 Form Identifier Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 645 665 FRM 5520 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Form Identification Code Loop FRM Supporting Documentation To specify information in response to a codified questionnaire document Usage notes The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes No questions, FRM03 for text uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQUT08.02 ). Example FRM XXXX W XXXXX 20250131 00 At least one of Question Response (FRM-02), Question Response (FRM-03), Question Response (FRM-04) or Question Response (FRM-05) is required Max use 99 Required FRM-01 350 Question Number Letter Min 1 Max 20 String (AN) Required Alphanumeric characters assigned for differentiation within a transaction set FRM01 is the question number on a questionnaire or codified form. FRM-02 1073 Question Response Identifier (ID) Optional Code indicating a Yes or No condition or response FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01. N No W Not Applicable Y Yes FRM-03 127 Question Response Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier FRM-04 373 Question Response CCYYMMDD format Date (DT) Optional 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 646 665 2440 Form Identification Code Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end 2000C Patient Hierarchical Level Loop end 2000B Subscriber Hierarchical Level Loop end 2000A Billing Provider Hierarchical Level Loop end Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year FRM-05 332 Question Response Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) SE 5550 Detail SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 0 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 647 665 Detail end The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 648 665 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 00000 00000000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 649 665 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 00000 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 650 665 EDI Samples Example 1: Commercial Health Insurance ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0211 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021108 000000001 X 005010X222A2 ST 837 0021 005010X222A2 BHT 0019 00 244579 20061015 1023 CH NM1 41 2 PREMIER BILLING SERVICE 46 TGJ23 PER IC JERRY TE 3055552222 EX 231 NM1 40 2 KEY INSURANCE COMPANY 46 66783JJT 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 MIAMI FL 33111 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 NM1 QC 1 SMITH TED N3 236 N MAIN ST N4 MIAMI FL 33413 DMG D8 19730501 M CLM 26463774 100 11 B 1 Y A Y I REF D9 17312345600006351 HI BK 0340 BF V7389 LX 1 SV1 HC 99213 40 UN 1 1 DTP 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 LX 4 SV1 HC 86663 10 UN 1 2 DTP 472 D8 20061010 SE 42 0021 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 651 665 Example 10a: Drug administered in the Physician Office ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0211 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021120 000000001 X 005010X222A2 ST 837 0711 005010X222A2 BHT 0019 00 0013 20040801 1200 CH NM1 41 2 Associates in Medicine 46 587654321 PER IC Bud Holly TE 8017268899 NM1 40 2 XYZ Receiver 46 369852758 HL 1 20 1 NM1 85 2 Associates in Medicine XX 587654321 N3 1313 Las Vegas Boulevard N4 Las Vegas NV 89109 REF EI 587654321 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 89109 DMG D8 19430501 M NM1 PR 2 R R Health Plan XV PLANID12345 CLM CLMNO12345 103.37 11 B 1 Y A Y Y HI BK 03591 NM1 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 HC J1550 53.37 UN 1 11 1 DTP 472 D8 20040711 AMT T 3.37 LIN N4 00026063512 CTP 10 ML SE 31 0711 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 652 665 Example 11: PPO Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0211 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021132 000000001 X 005010X222A2 ST 837 1002 005010X222A2 BHT 0019 00 1002 20050620 09460000 CH NM1 41 2 REGIONAL PPO NETWORK 46 123456789 PER IC SUBMITTER CONTACT INFO TE 8001231234 NM1 40 2 EXTRA HEALTHY INSURANCE 46 112244 HL 1 20 1 NM1 85 2 HAPPY DOCTORS GROUP PRACTICE XX 1234567890 N3 P O BOX 123 N4 FORT WAYNE IN 462540000 REF EI 555512345 PER IC SUE BILLINGSWORTH TE 8881231234 HL 2 1 22 0 SBR P 18 123XYZ CI NM1 IL 1 RING DIAMOND D MI 00124A089 N3 123 EXAMPLE DRIVE N4 INDIANAPOLIS IN 462290000 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 0902352342 REF D9 061505501749388 HI BK 496 BF 25000 HCP 03 26.75 2 908231234 NM1 DN 1 DOE JOHN XX 9988776655 NM1 82 1 ANTHONY SUSAN B XX 1122334455 NM1 77 2 HAPPY DOCTORS GROUP 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 1.25 908231234 LX 2 SV1 HC A7003 NU 3.75 UN 1 1 DTP 472 D8 20050514 HCP 03 3.75 908231234 SE 37 1002 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 653 665 Example 12: Out of Network Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0211 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021145 000000001 X 005010X222A2 ST 837 1024 005010X222A2 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 EMERGENCY PHYSICIANS GROUP XX 1122334455 N3 7423 SUPER STREET N4 BILLINGS MO 919910000 REF EI 111002222 HL 2 1 22 1 SBR P 232AA CI NM1 IL 1 SMITH MATTHEW R MI 57976235C N3 5698 SOUTH STREET N4 BILLINGS MO 919910000 DMG D8 19561015 M NM1 PR 2 CONSERVATIVE 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 0902345406 REF D9 687534234346 HI BK 9951 HCP 00 0 333001234 T1 NM1 82 1 BLUE JACKIE D XX 1112223336 SBR S 18 56567 CI 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 39 1024 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 654 665 Example 2: Encounter ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0212 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021201 000000001 X 005010X222A2 ST 837 0021 005010X222A2 BHT 0019 00 0123 20061015 1023 RP NM1 41 2 PREMIER BILLING SERVICE 46 TGJ23 PER IC JERRY TE 3055552222 EX 231 NM1 40 2 AHLIC 46 66783JJT 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 MIAMI FL 33111 HL 2 1 22 0 SBR P 18 12312-A HM NM1 IL 1 SMITH TED MI 000221111 N3 236 N MAIN ST N4 MIAMI FL 33413 DMG D8 19430501 M NM1 PR 2 ALLIANCE HEALTH AND LIFE INSURANCE PI 741234 CLM 26462967 100 11 B 1 Y A Y I DTP 431 D8 19981003 REF D9 17312345600006351 HI BK 0340 BF V7389 NM1 77 2 KILDARE ASSOCIATES XX 5812345679 N3 2345 OCEAN BLVD N4 MIAMI FL 33111 LX 1 SV1 HC 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 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 655 665 Example 3a: Claim from Billing Provider to Payer A ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0212 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021212 000000001 X 005010X222A2 ST 837 0021 005010X222A2 BHT 0019 00 0123 20051015 1023 CH NM1 41 2 PREMIER BILLING SERVICE 46 TGJ23 PER IC JERRY TE 3055552222 NM1 40 2 XYZ REPRICER 46 66783JJT HL 1 20 1 NM1 85 1 KILDARE BEN XX 1999996666 N3 234 SEAWAY ST N4 MIAMI FL 33111 REF EI 123456789 PER IC CONNIE TE 3055551234 NM1 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 19430501 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 33413 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 KILDARE ASSOCIATES XX 1581234567 N3 2345 OCEAN BLVD N4 MIAMI FL 33111 SBR S 01 CI OI Y P Y NM1 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 SV1 HC 90782 15 UN 1 1 2 DTP 472 D8 20051003 LX 3 SV1 HC J3301 21.04 UN 1 1 2 DTP 472 D8 20051003 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 656 665 SE 52 0021 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 657 665 Example 4: Medicare Secondary Payer (COB) ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0210 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021055 000000001 X 005010X222A2 ST 837 0002 005010X222A2 BHT 0019 00 000001142 20050214 115101 CH NM1 41 2 SPECIALISTS 46 1111111 PER IC SUE TE 8005558888 NM1 40 2 MEDICARE PENNSYLVANIA 46 10234 HL 1 20 1 NM1 85 2 SPECIALISTS XX 0100000090 N3 5 MAP COURT N4 MAYNE PA 17111 REF EI 890123456 REF 1G 110101 HL 2 1 22 0 SBR S 18 MEDICARE 12 MB NM1 IL 1 MEDYUM WAYNE M MI 102200221B1 N3 1010 THOUSAND OAK LANE N4 MAYN PA 17089 DMG D8 19560110 M NM1 PR 2 MEDICARE PENNSYLVANIA PI 10234 N3 5232 MAYNE AVENUE N4 LYGHT PA 17009 CLM 101KEN6055 120 11 B 1 Y A Y Y P HI BK 71516 BF 71906 NM1 DN 1 BRYHT LEE T REF 1G B01010 NM1 82 1 HENZES JACK XX 9090909090 PRV PE PXC 207X00000X REF G2 110102CCC SBR P 01 COMMERCE CI AMT D 80 AMT A8 15 OI Y P Y NM1 IL 1 MEDYUM CAROL 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 DTP 472 D8 20050119 SVD 59999 80 HC 99203 25 1 CAS CO 42 25 CAS PR 2 15 DTP 573 D8 20050128 SE 43 0002 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 658 665 Example 5: Ambulance ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0212 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021237 000000001 X 005010X222A2 ST 837 000017712 005010X222A2 BHT 0019 00 000017712 20050208 1112 CH NM1 41 2 AAA AMBULANCE SERVICE 46 376985369 PER IC LISA SMITH TE 3037752536 NM1 40 2 MEDICARE B 46 123245 HL 1 20 1 PRV BI PXC 3416L0300X NM1 85 2 AAA AMBULANCE SERVICE XX 2366554859 N3 12202 AIRPORT WAY N4 BROOMFIELD CO 800210021 REF EI 376985369 HL 2 1 22 0 SBR P 18 MB NM1 IL 1 JONES SARAH A MI 012345678A N3 1129 REINDEER ROAD N4 CARR CO 80612 DMG D8 19630729 F NM1 PR 2 MEDICARE PART B PI 123245 N3 PO BOX 3543 N4 BALTIMORE MD 666013543 CLM 051068 766.50 41 B 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 BANNOCK 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 CARDIAC 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 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 659 665 SE 52 000017712 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 660 665 Example 6: Chiropractic ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0212 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021257 000000001 X 005010X222A2 ST 837 3701 005010X222A2 BHT 0019 00 007227 20050215 075420 CH NM1 41 2 DAVID GREEN 46 S01057 PER IC KATHY SMITH TE 4105558888 NM1 40 2 MEDICARE PART B MARYLAND 46 12345 HL 1 20 1 NM1 85 1 GREENE DAVID M XX 1234567890 N3 1264 OAKWOOD AVE N4 BALTIMORE MD 21236 REF EI 987654321 PER IC DR TE 4105551212 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 20050115 DTP 453 D8 20050110 DTP 455 D8 20050113 CR2 A CHRONIC PAIN AND DISCOMFORT HI BK 7215 LX 1 SV1 HC 98940 145.5 UN 1 1 DTP 472 D8 20050215 REF 6R 01 SE 29 3701 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 661 665 Example 7: Oxygen ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0219 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021945 000000001 X 005010X222A2 ST 837 0001 005010X222A2 BHT 0019 00 16 20050326 1036 CH NM1 41 2 OXYGEN SUPPLY COMPANY 46 ABC11111 PER IC BONNIE TE 8125551111 EM HELPDESK OXYGEN.COM NM1 40 2 DMERC CARRIER 46 99999 HL 1 20 1 NM1 85 2 OXYGEN SUPPLY COMPANY XX 9992233334 N3 1800 EAST RIDGE DRIVE N4 RICHMOND IN 46224 REF EI 389999999 HL 2 1 22 0 SBR P 18 MB NM1 IL 1 SMITH TERRY MI 111222333A N3 121 SOUTH ST N4 RICHMOND IN 46236 DMG D8 19380105 F NM1 PR 2 DMERC CARRIER PI 99999 CLM R03996273 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 20050321 NM1 DK 1 WILSON LARRY XX 5555511111 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 20050321 DTP 463 D8 20040321 DTP 461 D8 20050321 NM1 DK 1 WILSON LARRY XX 5555511111 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 662 665 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 SE 66 0001 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 663 665 Example 8: Wheelchair ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0214 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021406 000000001 X 005010X222A2 ST 837 112233 005010X222A2 BHT 0019 00 16 20050326 1036 CH NM1 41 2 XYZ WHEELCHAIRS INC 46 ABC55 PER IC JANE TE 2225551111 NM1 40 2 DMERC CARRIER 46 99999 HL 1 20 1 NM1 85 2 XYZ WHEELCHAIR INC XX 7778889999 N3 1440 NORTH STREET N4 LAFAYETTE IN 47904 REF EI 123567989 REF 1G 0426960001 HL 2 1 22 0 SBR P 18 MB PAT 01 155 NM1 IL 1 SMITH JAMES MI 987654321A N3 12 MAIN ST N4 FRANKFORT IN 46209 DMG D8 19201023 M NM1 PR 2 DMERC CARRIER PI 99999 CLM SMI123 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 20050321-20050321 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 LEE 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 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 664 665 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 9: Anesthesia ISA 00 00 ZZ SENDER ZZ RECEIVER 231030 0214 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231030 021427 000000001 X 005010X222A2 ST 837 0001 005010X222A2 BHT 0019 00 0123 20050117 1023 CH NM1 41 2 PROVIDER MEDICAL GROUP 46 N305 PER IC NINA TE 6155551212 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 SBR P 18 MB NM1 IL 1 JONES MARGARET MI 123456789A N3 123 RAINBOW ROAD N4 NASHVILLE TN 37232 DMG D8 19740303 F NM1 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 PRV PE PXC 207L00000X REF G2 9741234 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 29 0001 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view home-state-health health-care-claim-professional-x222a2 01H25M3DFZT8BN5QV8WP430GEQ 665 665 | /kaggle/input/edi-db-835-837/Home State Health 837 Health Care Claim_ Professional.pdf | 27b51894711aa342918686b13db178cd | 27b51894711aa342918686b13db178cd_18 |
835 Transaction Companion Guide ANSI x12 Version 005010X221A1 General Guidelines August 201 5 CDPHP 835 TRANSACTION COMPANION GUIDE 2 Table of Contents Disclosure..................................................................................................................................... 3 Preface.......................................................................................................................................... 3 1. Introduction............................................................................................................................ 4 Scope...................................................................................................................................... 5 Overview................................................................................................................................ 5 2. Getting started........................................................................................................................ 5 Electronic Data Interchange Enrollment................................................................................ 5 Electronic Funds Transfer...................................................................................................... 5 835 Electronic Remittance Advice (ERA)............................................................................. 5 Questions and General Information....................................................................................... 5 3. Certification and Testing Overview....................................................................................... 6 Test Plan................................................................................................................................. 6 Security.................................................................................................................................. 6 4. Connectivity........................................................................................................................... 7 Prerequisites........................................................................................................................... 7 Supported Web Browsers....................................................................................................... 7 Supported Secure FTP SSL Clients....................................................................................... 7 Supported Secure FTP SSH (and SCP2) Clients................................................................... 8 Passwords............................................................................................................................... 9 5. Contact Information............................................................................................................... 9 CDPHP Hours of Operation................................................................................................... 9 6. Control Segments Envelopes............................................................................................... 10 7. Trading Partner Agreements................................................................................................ 1 0 8. Transaction Specific Information......................................................................................... 10 General Statements............................................................................................................... 10 Health Reimbursement Arrangement (HRA) Information................................................. 16 Coordination of Benefit Information in the 835 Transaction.............................................. 16 Appendix.................................................................................................................................... 17 CDPHP 835 TRANSACTION COMPANION GUIDE 3 Disclosure This document is based on requirements of the Affordable Care Act (ACA). All rights are reserved. This document is provided as is without any express or implied warranty. The Washington Publishing Company documentation was prepared for use by all health insurance payers in the United States. The CDPHP 835 ANSI Companion Guide Document is a supplement but does not contradict any requirements in the ASC X12N 835 (005010X221A1) data standards, as mandated by Health and Human Services. Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Capital District Physicians Health Plan, Inc. (CDPHP ). Transmissions based on this companion guide, used in conjunction with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides, all of which are available from the Washington Publishing Company website at: www.wpc-edi.com. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. CDPHP 835 TRANSACTION COMPANION GUIDE 4 1. Introduction This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that CDPHP has something additional, over and above, the information in the IGs. That information can: 1. Limit the repeat of loops or segments 2. Limit the length of a simple data element 3. Specify a subset of the IG s internal code listings 4. Clarify the use of loops, segments, composite, and simple data elements 5. Any other information tied directly to a loop, segment, composite, or simple data element pertinent to trading electronically with CDPHP. In addition to the row for each segment, one or more additional rows are used to describe CDPHP s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. The following table is an example: Shaded Rows represent segments in the X12N Implementation Guide. Non-Shaded rows represent data elements in the X12N Implementation Guide. Loop Element Identifier Description ID Min Max Usage Loop Repeat Values Requirement Description HDR ISA Interchange Control Header 1 R Loop Repeat Values Requirement Description HDR ISA01 Authorized Information Qualifier ID 2-2 R 00,03 HDR ISA02 Security Information Qualifier ID 2-2 R 00,01 HDR ISA05 Interchange ID Qualifier ID 2-2 R 01, 14, 20, 27, 28, 29, 30, 33, ZZ Use ZZ Mutually Defined CDPHP 835 TRANSACTION COMPANION GUIDE 5 Scope This document is to be used in addition to the HIPAA 835 Implementation Guide. It is designed for implementation of the HIPAA Transaction for Health Care Claim Payment Advice, also known as the Electronic Remittance Advice (ERA). Overview This Companion Guide will replace any previous CDPHP Companion Guide for 835 Health Care Claim transactions. This Companion Guide will assist you in designing and implementing 835 Claim Payment Advice transactions that meet CDPHP s processing standards. The CDPHP Companion Guide identifies key data elements that we request be sent in the submitting transaction set. Adherence to these guidelines will enable you to more effectively process 835 claims from CDPHP. 2. Getting started Electronic Data Interchange Enrollment Should you decide to receive your payments and or claim payment remittance advice electronically, you must first complete and return the necessary enrollment forms applicable to the transaction(s) your organization is requesting. Please contact your financial institution to arrange for the delivery of the CORE (Committee on Operating Rules for Information Exchange)-required Minimum CCD (Corporate Credit or Debit entry) data elements needed for reassociation of the payment and the Electronic Remittance Advice (ERA). Electronic Funds Transfer To enroll for Electronic Funds Transfer (EFT), you ll need to complete your enrollment request by registering at https: CDPHP.payeehub.org and establishing a user account that will give you access as an authorized agent to request set up of EFT payments. To modify an existing EFT enrollment, you will also need to be a registered user at https: CDPHP.payeehub.org 835 Electronic Remittance Advice (ERA) Enrollment to receive an 835 Electronic Remittance Advice is a separate sign up process and requires a Group Provider Access Information for 835 Transaction Set Form which can be found online at: http: www.cdphp.com media Files providers 835-Access-Request-Form-FIELDS-FINAL.ashx Once CDPHP receives your enrollment request, a CDPHP employee will establish your organization as an eligible EDI Trading Partner with CDPHP and contact you to discuss next steps in getting set up to trade electronic data. Questions and General Information For assistance with any questions and or general information regarding the sign up process, please contact: CDPHP 835 TRANSACTION COMPANION GUIDE 6 CDPHP Provider Relations Team E_TRANSACTION_HELP CDPHP.COM 3. Certification and Testing Overview Becoming HIPAA compliant will require providers and payers to make significant changes to their existing Electronic Data Interchange (EDI) process. Process change inevitably includes testing for results validation. This testing can be one of the most time-consuming efforts in the development process. CDPHP expects the following approach will optimize test time and expedite our trading partners transition from test to production status. The trading partner must complete testing for each of the transactions they will implement and shall not be allowed to exchange data with CDPHP in production mode until testing has passed as determined by CDPHP. Successful testing means the ability to successfully pass HIPAA compliance checks and to process protected health information (PHI) transmitted by the trading partner to CDPHP. Test Step Description Test Plan The CDPHP EDI Support Center and trading partner will agree to a predefined set of test data with expected results. This matrix will vary by trading partner. Security CDPHP will verify that trading partners have a valid user ID and password. Connectivity and Transmission Integrity CDPHP connectivity protocols are outlined in 4. Connectivity. We suggest that the trading partner limit transactions to a small volume during the testing phase. Transaction Validation CDPHP will verify that the trading partner is submitting transactions allowed per their enrollment applications. Data Integrity Data integrity is determined by the X12 and HIPAA Implementation Guide. The trading partner should correct transactions reported as errors and resubmit them. Data integrity testing is successfully completed when the trading partner s data has no compliance errors. Acknowledgment and Response Transactions Trading partners must demonstrate the ability to receive acknowledgment and response transactions. Result Analysis CDPHP and the trading partner will review the acknowledgment and response transaction for consistency with the predefined results. CDPHP 835 TRANSACTION COMPANION GUIDE 7 4. Connectivity Prerequisites An Internet connection. Ability to connect to a HTTPS Web site. Desktop Web browser. Browsers supported are: Mozilla v.1.0 and higher Advantages File transfers are not time consuming. Can use existing desktop browsers and Internet connectivity to transfer files. Browser-based solutions are well-suited for on-demand, manual transfers involving desktops and laptops because they are free, already installed, and end-users know how to use the existing software. Files are protected in transit by SSL (Secure Socket Layer). There is no need to send encrypted files. Supported Web Browsers MOVEit DMZ has been tested against and fully supports the following major browsers: Internet Explorer version 6.0 and higher o Internet Explorer 7.0 and higher preferred o when using MOVEit Upload Download Wizard (ActiveX or Java) FireFox (2.0 and 3.0) o when using MOVEit Upload Download Wizard (Java Windows nix Mac OS X) Safari (versions 2 and 3) under Macintosh OS X o o when using MOVEit Upload Download Wizard (Java Only) Indicates this client ensures the integrity of transferred files and proves who uploaded and who downloaded a specific file (non-repudiation). Use of the MOVEit Java Wizard on the Macintosh version of Firefox requires that you use the Java Preferences applet to select Java 1.5 (rather than 1.4.2). Supported Secure FTP SSL Clients MOVEit DMZ has been tested against and fully supports a large number of secure FTP clients using FTP over SSL: CDPHP 835 TRANSACTION COMPANION GUIDE 8 MOVEit Freely (free command-line) MOVEit Buddy (GUI) MOVEit Central (w Admin) WS_FTP Professional and WS_FTP Home (GUI, version 7 and higher, Windows) ( version 12 and higher) SmartFTP (GUI, version 1.6 and higher, Windows) SmartFTP (free GUI, version 1.0 and higher, Windows) Cute FTP Pro (GUI, version 1.0 and higher, Windows) BitKinex (GUI, version 2.5 and higher, Windows) Glub FTP (GUI, Java 2.0 and higher) FlashFXP (GUI, version 3.0 and higher) IP Works SSL (API, Windows, version 5.0) LFTP (free command-line, Linux, Unix, Solaris, AIX, etc.) NetKit (command-line, Linux, Unix, Solaris, etc.) SurgeFTP (command-line, FreeBSD, Linux, Macintosh, Windows, Solaris) C-Kermit (command-line; v8.0, AIX, VMS, Linux, Unix, Solaris) AS 400 native FTPS client (OS 400 minicomputer) z OS Secure Sockets FTP client (z OS mainframe) TrailBlaxer ZMOD (OS 400 minicomputer) NetFinder (GUI, Apple) Sterling Commerce (batch, various) Tumbleweed SecureTransport (4.2 on Windows, batch, various) Cleo Lexicom (batch, various) bTrade TDAccess (batch, AIX, AS 400, HP-UX, Linux, MVS, Solaris, Windows) cURL (command-line, AIX, HP-UX, Linux, QNX, Windows, AmigaOS, BeOS, Solaris, BSD and more) South River Technologies "WebDrive" (Windows "drive letter" - requires "passive, implicit and 'PROT P'" options) Stairways Software Pty Ltd. "Interarchy" (Mac "local drive" and GUI ) FTP Client Developers: Please consult the "FTP - Interoperability - Integrity Check How-To" documentation for information about how to support integrity checks with your FTP client too. Supported Secure FTP SSH (and SCP2) Clients MOVEit DMZ has been tested against and fully supports the most popular secure FTP clients using FTP over SSH as well: OpenSSH sftp for nix (free command-line, Unix - including Linux and BSD, password and client key modes) OpenSSH for Windows (free command-line, Windows, password and client key modes) OpenSSH sftp for Mac (preinstalled command-line, Mac, password and client key modes) OpenSSH sftp for z OS (part of "IBM Ported Tools for z OS", z OS 1.4, password and client key modes) Putty PSFTP, (command-line, Windows, password and client key modes) CDPHP 835 TRANSACTION COMPANION GUIDE 9 WS_FTP (GUI, Windows, version 7.0 and higher; version 7.62 has a compression-related bug which prevents it from uploading large, highly compressible files) BitKinex (GUI, version 2.5 and higher, Windows) F-Secure SSH (command-line, 3.2.0 Client for Unix, password and client key modes) FileZilla (GUI, Windows) SSH Communications SSH Secure Shell FTP (GUI, Windows, password and client key modes; requires setting of transfers to 1) SSH Tectia Connector (Windows) SSH Tectia Client (Windows,AIX,HP-UX,Linux,Solaris) J2SSH (free Java class - requires Java 1.3 ) Net::SFTP - Net::SSH::Perl (free Perl module for Unix) MacSSH (GUI, Mac, password mode only) Fugu (free GUI, Mac, password mode only) Cyberduck (free GUI, Mac, password and client key modes) Rbrowser (GUI, Mac, password mode only) Transmit2 (GUI, Mac, password and client key modes) gftp (GUI, Linux, password and client key modes) Magnetk LLC sftpdrive (Windows "drive letter", password mode only) South River Technologies "WebDrive" (Windows "drive letter", password mode only) Cyclone Commerce Interchange (Solaris, client key mode only) Stairways Software Pty Ltd. "Interarchy" (Mac "local drive" and GUI, password mode only) Miklos Szeredi's "SSH FileSystem", a.k.a. "SSHFS" ( nix "mount file system" utility, password and client key modes; requires OpenSSH and FUSE) Tumbleweed SecureTransport (4.2 on Windows, batch, various) Indicates this client ensures the integrity of transferred files and proves who uploaded and who downloaded a specific file (non-repudiation). Passwords Passwords must be changed upon first log-on. Passwords and user names are case sensitive. Passwords must be six characters. Passwords must contain at least one alpha and one numeric character. Passwords cannot resemble user names. Passwords cannot contain dictionary words. Examples: Unacceptable passwords: Security, Security 9 Acceptable passwords: Sec9urity, sec9urity 5. Contact Information For assistance regarding 835 ERA enrollment, EDI technical assistance, or general provider services, please email our EDI Customer Service at E_Transaction_Help cdphp.com CDPHP 835 TRANSACTION COMPANION GUIDE 10 By visiting https: CDPHP.payeehub.org you can access information about how to register and enroll to receive Electronic Funds Transfer (EFT) payments, and or how to make modifications to your existing EFT enrollment. CDPHP Hours of Operation CDPHP business areas process non-inquiry files Monday through Friday. Files may be submitted 24 hours a day, 7 days a week, 365 days a year. Files received after 2 p.m. EST will be processed the next business day. CDPHP does NOT process claims on the following days: Saturday Sunday New Year s Day President s Day Memorial Day Independence Day Labor Day Thanksgiving Friday following Thanksgiving Christmas Eve Day Christmas Day Under normal operating conditions, 835 files are available for pick up no later than noon, EST every Tuesday of each week. The above list is subject to change. Days may be added or removed from the list without notice. 6. Control Segments Envelopes ASC X12 transaction envelopes (i.e., ISA, IEA, GS and GE segments) should be populated per instructions found in the section labeled 8. Transaction Specific Information. Transactions returned by CDPHP to the trading partner will be enveloped consistent with the specifications described in Example 1B. ASC X12 transaction record formats are available as downloads from The Washington Publishing Company (WPC), website: http: Wpc-Edi.Com 7. Trading Partner Agreements An EDI Trading Partner is defined as any CDPHP customer (provider, billing service, software, software vendor, etc.) that transmits to, or receives electronic data from CDPHP. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party agreement. 8. Transaction Specific Information CDPHP 835 TRANSACTION COMPANION GUIDE 11 The following information is intended to serve as a guide to the HIPAA ANSI X12 835 Implementation Guide. Please refer to the complete HIPAA ANSI x12 835 Implementation Guide for a full listing of required and situational fields. The rules in the implementation guide take precedence over the CDPHP companion guide. General Statements The outbound 835 transactions utilize delimiters from the following list:,,,,, and:. CDPHP utilizes:. If you need this changed, please contact CDPHP, or else the: is assumed. Transaction File Naming Structure File Name: 835 files received from CDPHP will be named using a standard naming convention. File names contain four parts separated by underscore characters and end with an.edi extension. The parts of the file name are: Trading Partner No: Typically a Tax Identification number. Sequence number: Unlimited characters. The sequence number will be used by CDPHP to identify a file as unique for that trading partner on a given day. Transaction Type: 835 File Extension: edi Example of filename: 123456789_54126_916740_835.edi Version Loop Segment Field Description Suggestion HDR ISA Interchange Control Header 005010X221A1 - ISA 05 Interchange ID Qualifier Value of "30" - Federal Tax ID 005010X221A1 ISA 06 Interchange Sender ID 141641028 005010X221A1 ISA 07 Interchange ID Qualifier Value of "30" - Federal Tax ID 005010X221A1 ISA 08 Interchange Receiver ID Receiver's Tax ID Version Loop Segment Field Description Suggestion CDPHP 835 TRANSACTION COMPANION GUIDE 12 HDR GS Functional Group Header 005010X221A1 - GS 02 Application Sender's Code 141641028 005010X221A1 - GS 03 Application Receiver's Code Same value as what was in ISA08 for consistency Version Loop Segment Field Description Suggestion HDR BPR Financial Information 005010X221A1 - BPR 04 Payment Method Code CDPHP will utilize all available Payment Method codes: ACH Automated Clearing House CHK Check NON Non-Payment Data BPR 05 Payment Format Code CCP Cash Concentration Disbursement plus Addenda BPR05 will only be valued when BPR04 is ACH. BPR 10 Originating Company Identifier 141641028 (Only when BPR04 is ACH.) Version Loop Segment Field Description Suggestion HDR TRN Re-Association Trace Number 005010X221A1 - TRN 02 Check or EFT Trace Number If BPR04 ACH TRN02 Re-association Trace Number on EFT Transaction 005010X221A1 - TRN 03 Originating Company Identifier Tax ID of Business Program Group Administering Benefit CDPHP 835 TRANSACTION COMPANION GUIDE 13 005010X221A1 - TRN 04 Originating Company Supplemental Code If BPR04 ACH, The same value as BPR10 ( originating Company Supplemental Code is used) IF BPR04 CHK or NON, The RA Advice Number is used. Version Loop Segment Field Description Suggestion HDR CUR Foreign Currency Information 005010X221A1 - CUR All Foreign Currency Segment CDPHP will not use this segment. All funds will be in US dollars Version Loop Segment Field Description Suggestion 1000 A Payer Identification 005010X221A1 1000 A N1 02 Payer Name Name of Business Program Group Administering Benefit 005010X221A1 1000 A N1 04 Payer Identifier CDPHP as the entity to contact with questions 005010X221A1 1000 A REF 01 Reference Identification Qualifier 2U 005010X221A1 1000 A REF 02 Additional Payer Identifier SX065_12X03 (professional and institutional identifiers) Version Loop Segment Field Description Suggestion 1000 B Payee Identification 005010X221A1 1000 B N1 03 Identification Code Qualifier Value of "XX" - National Provider ID 005010X221A1 1000 B N1 04 Identification Code NPI Number CDPHP 835 TRANSACTION COMPANION GUIDE 14 005010X221A1 1000 B REF 01 Reference Identification Qualifier Value of "TJ" - Payee Identification 005010X221A1 1000 B REF 02 Reference Identification The "pay to" Tax Identification number on file with CDPHP Version Loop Segment Field Description Suggestion 2100 NM1 Corrected Priority Payee Name 005010X221A1 2100 NM1 01 Entity Identifier Code QC 005010X221A1 2100 NM1 08 Identification Code Qualifier Value "MI" -Member Identification Number 005010X221A1 2100 NM1 09 Identification Code - Patient Identifier Member ID including suffix 005010X221A1 2100 NM1 01 Entity Identifier Code IL - This segment will only be used if the insured or subscriber is difference from the patient. 005010X221A1 2100 NM1 08 Identification Code Qualifier Value "MI" -Member Identification Number 005010X221A1 2100 NM1 09 Identification Code - Insured Identifier Member ID including suffix Additional Information in the 835 Transaction The following is intended to highlight additional information that may be returned from CDPHP on an 835. This information is compliant with HIPAA ANSI X12 835 but may be new to you. Claim Adjustment Group and Reason Codes CDPHP utilizes the Washington Publishing Company for 835 claim adjustment reason codes and remittance advice remark codes: Refer to www.wpc-edi.com for information. Version Loop Segment Field Value Description 2100 CAS Claim Adjustment 005010X221A1 2100 2110 CAS 01 PR CO PI OA CDPHP will utilize all available claim adjustment group codes: 6. PR Patient Responsibility 7. CO Contractual Obligations 8. PI - Payer Initiated Reductions 9. OA Other Adjustments CDPHP 835 TRANSACTION COMPANION GUIDE 15 005010X221A1 2110 CAS 01 02 PR 95 Patient Responsibility In addition to a patient responsibility for co-pay, coinsurance, and deductible, patient responsibility can also be the result of a contractual provision between the patient and insurer. Claim Adjustment Reason Code 95 will be used to indicate a patient responsibility that is the result of a penalty being applied when member contract provisions are not followed. 005010X221A1 2110 CAS 01 PI 45 PI 94 Payer Initiated Reductions Inpatient or Outpatient Per Diem or an APC or APG or ASC reimbursement: The PI (45) segment represents the total of all other individual line items disallowed due to the per diem. DRG or Outpatient Flat Rate reimbursement The PI (94) segment represents the difference between the flat rate and the submitted charge when the submitted charge is less than the negotiated rate. This will result in a negative dollar amount. 005010X221A1 2110 CAS 01 02 CO 104 Contractual Obligation In addition to the normal contractual obligation disallows, CO will also be used for Managed Care Withholding. This disallow segment represents the amount of the CDPHP allowance withheld (aka risk) as part of the provider s contractual agreement with CDPHP. Risk is applied on claims where CDPHP is processing as secondary, as well as primary. 005010X221A1 2100 CAS DRG Reimbursement Reimbursement of DRG claims will be reflected at the claim level rather than the line level. There will be no 2110 loop. Version Loop Segment Field Value Description 2110 CAS Service Adjustment 005010X221A1 2110 CAS 01 PR CO PI OA CDPHP will utilize all available claim adjustment group codes: 10. PR Patient Responsibility 11. CO Contractual Obligations 12. PI - Payer Initiated Reductions 13. OA Other Adjustments CDPHP 835 TRANSACTION COMPANION GUIDE 16 Version Loop Segment Field Value Description PLB Service Adjustment 005010X221A1 PLB 03-02 Provider Adjustment Identifier will contain both the CDPHP claim number and provider patient account number. ie: 1513300XXX00 123456XY22Z Health Reimbursement Arrangement (HRA) Information on CDPHP 835 Outbound File In the event that a member has an HRA administered by CDPHP and it is a fully automated plan, patient liability, with the exception of penalty, will be considered for an additional payment according to the member s employer group rules. In the event that an additional payment is created, the medical payment will appear on your 835 as a medical claim as reflected above and it will also appear on your 835 as an HRA considered claim. The HRA portion will be attached to the Payer Capital District Physicians Healthcare Network CD. See below: N1 PR Capital District Physicians Healthcare Network CD Coordination of Benefit Information in the 835 Transaction The following is intended to explain the COB information on the 835. Claim adjustment reason code 22 is used to indicate Other Carrier Paid Amount. This code may be associated with the following group codes: CO, OA and PR. This is because when mapping the COB amounts, it is necessary to offset the patient responsibility (PR) with the COB amount. When COB amount is in excess of the patient responsibility amount, the difference will be applied to the next CAS segment. Adjustment reason code 23 often reflects the difference between the CDPHP allowance and the primary carrier s allowance. Finally, CDPHP supports COB savings in which denied or non covered services may be reimbursed out of a savings that has been established for the member and based on the savings CDPHP has received through coordination of benefits. The following is an example of what you could see returned on the 835 when there is credit banking involved: CLP 2091830396PR 2 54 0 32 15 XXXXXXXXXXXX 23 CDPHP 835 TRANSACTION COMPANION GUIDE 17 NM1 QC 1 WONKA WILLY MI ABCD1234F00 NM1 74 1 Wonka Willy C F ABCD1234F NM1 82 1 Brown MD Michael E XX 321456ABCD REF 1L 10008559 DTM 050 20090711 SVC HC:93971 26 LT 54 0 1 DTM 472 20090628 CAS PR 204 54 23 -22 CAS OA 22 22 CDPHP 835 TRANSACTION COMPANION GUIDE 18 Appendix Change Summary: Date Version Description Oct. 2015 2 Added N1, REF segments to loop 1000A to reference additional payers; PLB segment now contains CDPHP claim number and provider patient account number Dec. 2021 3 (Dan M.) Changed CAQH text and links to new EFT administrator Zelis Healthcare and their custom CDPHP portal https: CDPHP.payeehub.org July 2022 4 (Dan M.) Added the following text to Page 5: Please contact your financial institution to arrange for the delivery of the CORE (Committee on Operating Rules for Information Exchange)-required Minimum CCD (Corporate Credit or Debit entry) data elements needed for reassociation of the payment and the Electronic Remittance Advice (ERA). | /kaggle/input/edi-db-835-837/835_companion_guide.pdf | 978359a285f20df034bb060dcb8e3304 | 978359a285f20df034bb060dcb8e3304_0 |
Page 1 of 18 Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X222A1 Health Care Claim Professional (837P) Companion Guide Version Number 6.2 March 8, 2023 Page 2 of 18 CHANGE LOG Version Release Date Changes 1.0 12 10 2010 Initial draft release 2.0 03 24 2014 ICD-10 effective date change to 10 01 2014 3.0 09 17 2015 ICD-10 effective date change to 10 01 2015 4.0 01 05 2018 Updated UnitedHealthcare and Optum contact information, including hyperlinks to online resources 5.0 10 17 2019 Updated corrected claim information in section 6.1 Electronic Claim Submission Guidelines 6.0 05 04 2020 Section 6 updated to include Laboratory test code requirement 6.1 06 23 2020 Removed Section 6 on the Laboratory test code requirement 6.2 03 08 2023 Updated Version Date Page 3 of 18 PREFACE This companion guide (CG) to the v5010 ASC X12N Technical Report Type 3 (TR3) adopted under Health Insurance Portability and Accountability Act (HIPAA) clarifies and specifies the data content when exchanging transactions electronically with UnitedHealthcare. Transmissions based on this companion guide, used in tandem with the TR3, also called 837 Health Care Claim: Professional ASC X12N (005010X222A1), are compliant with both ASC X12 syntax and those guides. There are separate transactions for Health Care Claims - institutional (837I) and professional (837P). This companion guide is intended to convey information that is within the framework of the ASC X12N TR3 adopted for use under HIPAA. The companion guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the TR3. The TR3, also known as X12N Implementation Guide (IG), adopted under HIPAA, here on in within this document will be known as IG or TR3. Page 4 of 18 Table of Contents CHANGE LOG..............................................................................................................................................................2 PREFACE.....................................................................................................................................................................3 INTRODUCTION............................................................................................................................................. 6 1.1 SCOPE.....................................................................................................................................................6 1.2 OVERVIEW..............................................................................................................................................7 1.3 REFERENCE.............................................................................................................................................7 1.4 ADDITIONAL INFORMATION.................................................................................................................7 GETTING STARTED........................................................................................................................................ 7 2.1 EXCHANGING TRANSACTIONS WITH UNITEDHEALTHCARE.................................................................7 2.2 CLEARINGHOUSE CONNECTION............................................................................................................7 2.3 CERTIFICATION AND TESTING................................................................................................................8 CONNECTIVITY AND COMMUNICATION PROTOCOLS................................................................................. 8 3.1 PROCESS FLOW: BATCH 837 INSTITUTIONAL CLAIM............................................................................8 3.2 TRANSMISSION ADMINISTRATIVE PROCEDURES.................................................................................8 3.3 RE-TRANSMISSION PROCEDURES..........................................................................................................8 3.4 COMMUNICATION PROTOCOL SPECIFICATIONS..................................................................................8 3.5 PASSWORDS...........................................................................................................................................9 3.6 SYSTEM AVAILABILITY...........................................................................................................................9 3.7 COSTS TO CONNECT...............................................................................................................................9 CONTACT INFORMATION............................................................................................................................. 9 4.1 EDI SUPPORT..........................................................................................................................................9 4.2 EDI TECHNICAL SUPPORT.......................................................................................................................9 4.3 PROVIDER SERVICES............................................................................................................................ 10 4.4 APPLICABLE WEBSITES EMAIL........................................................................................................... 10 CONTROL SEGMENTS ENVELOPES............................................................................................................. 10 5.1 ISA-IEA................................................................................................................................................. 10 5.2 GS-GE................................................................................................................................................... 10 5.3 ST-SE.................................................................................................................................................... 11 5.4 CONTROL SEGMENT HIERARCHY........................................................................................................ 11 5.5 CONTROL SEGMENT NOTES................................................................................................................ 11 5.6 FILE DELIMITERS.................................................................................................................................. 12 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS................................................................................ 12 6.1 ELECTRONIC CLAIM SUBMISSION GUIDELINES.................................................................................. 12 6.2 VALIDATION OF CLAIMS..................................................................................................................... 14 ACKNOWLEDGEMENTS AND REPORTS...................................................................................................... 14 Page 5 of 18 7.1 ACKNOWLEDGEMENTS....................................................................................................................... 14 7.2 REPORT INVENTORY........................................................................................................................... 15 TRADING PARTNER AGREEMENTS............................................................................................................. 15 8.1 TRADING PARTNERS........................................................................................................................... 15 TRANSACTION SPECIFIC INFORMATION.................................................................................................... 15 APPENDECIES.............................................................................................................................................. 17 10.1 IMPLEMENTATION CHECKLIST............................................................................................................ 17 10.2 FREQUENTLY ASKED QUESTIONS....................................................................................................... 17 10.3 FILE NAMING CONVENTIONS............................................................................................................. 18 Page 6 of 18 INTRODUCTION This section describes how Technical Report Type 3 (TR3), also called 837 Health Care Claim: Professional (837P) ASC X12N 005010X222A1, adopted under HIPAA, will be detailed with the use of a table. The tables contain a row for each segment that UnitedHealth Group has included, in addition to the information contained in the TR3s. That information can: 1. Limit the repeat of loops, or segments 2. Limit the length of a simple data element 3. Specify a sub-set of the TR3 s internal code listings 4. Clarify the use of loops, segments, composite and simple data elements 5. Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with UnitedHealthcare In addition to the row for each segment, one or more additional rows are used to describe UnitedHealthcare s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The table below specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. The table contains a row for each segment that UnitedHealthcare has included, in addition to the information contained in the TR3s. The following is an example (from Section 9 Transaction Specific Information) of the type of information that may be included: Page Loop ID Reference Name Codes Length Notes Comments 71 1000A NM1 Submitter Name This type of row always exists to indicate that a new segment has begun. It is always shaded at 10 and notes or comment about the segment itself goes in this cell. 114 2100C NM109 Subscriber Primary Identifier This type of row exists to limit the length of the specified data element. 114 2100C NM108 Identification Code Qualifier MI This type of row exists when a note for a particular code value is required. For example, this note may say that value MI is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it. 184 2300 HI Principal Diagnosis Code 2300 HI01-2 Code List Qualifier Code BK This row illustrates how to indicate a component data element in the Reference column and also how to specify that only one code value is applicable. 1.1 SCOPE This document is to be used for the implementation of the TR3 HIPAA 5010 837 Health Care Claim: Professional (referred to as Professional Claim or 837P Claim in the rest of this document) for the purpose of submitting an institutional claim electronically. This companion guide is not intended to replace the TR3. Page 7 of 18 1.2 OVERVIEW This CG will replace, in total, the previous UnitedHealthcare CG versions for Health Care Institutional Claim and must be used in conjunction with the TR3 instructions. This CG is intended to assist you in implementing electronic Institutional Claim transactions that meet UnitedHealthcare processing standards, by identifying pertinent structural and data related requirements and recommendations. Updates to this companion guide occur periodically and are available online. CG documents are posted in the Electronic Data Interchange (EDI) section of our Resource Library on the Companion Guides page: https: www.uhcprovider.com en resource-library edi edi-companion-guides.html In addition, trading partners can sign up for the Network Bulletin and other online news: https: uhg.csharmony.epsilon.com Account Register. 1.3 REFERENCE For more information regarding the ASC X12 Standards for Electronic Data Interchange 837 Health Care Claim: Institutional (005010X223A2) and to purchase copies of the TR3 documents, consult the Washington Publishing Company website: http: www.wpc-edi.com 1.4 ADDITIONAL INFORMATION The American National Standards Institute (ANSI) is the coordinator for information on national and international standards. In 1979 ANSI chartered the Accredited Standards Committee (ASC) X12 to develop uniform standards for electronic interchange of business transactions and eliminate the problem of non-standard electronic data communication. The objective of the ASC X12 Committee is to develop standards to facilitate electronic interchange relating to all types of business transactions. The ANSI X12 standards is recognized by the United States as the standard for North America. EDI adoption has been proved to reduce the administrative burden on providers. Please note that this is UnitedHealthcare s approach to 837 Professional claim transactions. After careful review of the existing IG for the Version 005010X222A1, we have compiled the UnitedHealthcare specific CG. We are not responsible for any changes and updates made to the IG. GETTING STARTED 2.1 EXCHANGING TRANSACTIONS WITH UNITEDHEALTHCARE UnitedHealthcare exchanges transactions with clearinghouses and direct submitters, also referred to as Trading Partners. Most transactions go through the Optum clearinghouse, OptumInsight, the managed gateway for UnitedHealthcare EDI transactions. 2.2 CLEARINGHOUSE CONNECTION Physicians, facilities and health care professionals should contact their current clearinghouse vendor to discuss their ability to support the 837 Health Care Claim: Professional transaction, as well as associated timeframes, costs, etc. This includes protocols for testing the exchange of transactions with UnitedHealthcare through your clearinghouse. Page 8 of 18 Optum: Physicians, facilities and health care professionals can submit and receive EDI transactions direct. Optum partners with providers to deliver the tools that help drive administrative simplification at minimal cost and realize the benefits originally intended by HIPAA standard, low-cost claim transactions. Please contact Optum Support at 800-341-6141 to get set up. If interested in using Optum s online solution, Intelligent EDI (IEDI), contact the Optum sales team at 866-367-9778, option 3, send an email to IEDIsales optum.com or visit https: www.optum.com campaign fp free-edi.html. 2.3 CERTIFICATION AND TESTING All trading partners who wish to submit 837P claim transactions to UnitedHealthcare via the ASC X12 837 (Version 005010X222A1), and receive corresponding EDI responses, must complete testing to ensure that their systems and connectivity are working correctly before any production transactions can be processed. For testing EDI transactions with UnitedHealthcare, care providers and health care professionals should contact their current clearinghouse vendor or Optum. CONNECTIVITY AND COMMUNICATION PROTOCOLS 3.1 PROCESS FLOW: BATCH 837 INSTITUTIONAL CLAIM 3.2 TRANSMISSION ADMINISTRATIVE PROCEDURES UnitedHealthcare supports both batch and real-time 837P claim transmissions. Contact your current clearinghouse vendor to discuss transmission types and availability. 3.3 RE-TRANSMISSION PROCEDURES Physicians, facilities and health care professionals should contact their current clearinghouse vendor for information on whether resubmission is allowed or what data corrections need to be made for a successful response. 3.4 COMMUNICATION PROTOCOL SPECIFICATIONS Physicians, facilities and health care professionals should contact their current clearinghouse for communication protocols with UnitedHealthcare. Provider or Provider s Clearinghouse Clearinghouse UnitedHealthcare Claim Files Claim Files 1st Level 999 277PRE ACKs and Reports 2nd Level 277 ACK Page 9 of 18 3.5 PASSWORDS Physicians, facilities and health care professionals should contact their current clearinghouse vendor to discuss password policies. 3.6 SYSTEM AVAILABILITY UnitedHealthcare will accept 837 claim transaction submissions at any time, 24 hours per day, 7 days a week. Unplanned system outages may occur occasionally and impact our ability to accept or immediately process incoming transactions. UnitedHealthcare will send an email communication for scheduled and unplanned outages. 3.7 COSTS TO CONNECT Clearinghouse Connection: Physicians, facilities and health care professionals should contact their current clearinghouse vendor or Optum to discuss costs. Optum: Optum Support 800-341-6141 Optum s online solution, Intelligent EDI (IEDI) Call 866-367-9778, option 3 Email IEDIsales optum.com Visit https: www.optum.com campaign fp free-edi.html CONTACT INFORMATION 4.1 EDI SUPPORT Most questions can be answered by referring to the EDI section of our resource library at UHCprovider.com Menu Resource Library Electronic Data Interchange (EDI): https: www.uhcprovider.com en resource-library edi.html. View the EDI 837: Electronic Claims page for information specific to 837 Claim transactions. If you need assistance with an EDI 837 transaction accepted by UnitedHealthcare, please contact EDI Support by: Using our EDI Transaction Support Form Sending an email to supportedi uhc.com Calling 800-842-1109 For questions related to submitting transactions through a clearinghouse, please contact your clearinghouse or software vendor directly. 4.2 EDI TECHNICAL SUPPORT Physicians, facilities and health care professionals should contact their current clearinghouse vendor or Optum for technical support. If using Optum, contact their technical support team at 800-225-8951, option 6. For issues with encounters, send an email to the Encounter Data Collection Team: encountercollection uhc.com Page 10 of 18 4.3 PROVIDER SERVICES Provider Services should be contacted at 877-842-3210 instead of EDI Support if you have questions regarding 837 Claim transactions that do not pertain to EDI. Provider Services is available Monday - Friday, 7 am - 7 pm in the provider s time zone. 4.4 APPLICABLE WEBSITES EMAIL Companion Guides: https: www.uhcprovider.com en resource-library edi edi-companion-guides.html Optum: https: www.optum.com OptumInsight Optum EDI Client Center - https: www.enshealth.com UnitedHealthcare Administrative Guide: https: www.uhcprovider.com content dam provider docs public admin- guides UnitedHealthcare_Administrative_Guide_2017.pdf UnitedHealthcare EDI Support: supportedi uhc.com or EDI Transaction Support Form UnitedHealthcare EDI Education website: https: www.uhcprovider.com en resource-library edi.html Washington Publishing Company: http: www.wpc-edi.com CONTROL SEGMENTS ENVELOPES 5.1 ISA-IEA Transactions transmitted during a session or as a batch are identified by an interchange header segment (ISA) and trailer segment (IEA) which form the envelope enclosing the transmission. Each ISA marks the beginning of the transmission (batch) and provides sender and receiver identification. The table below represents only those fields that UnitedHealthcare requires a specific value in or has additional guidance on what the value should be. The table does not represent all of the fields necessary for a successful transaction; the TR3 should be reviewed for that information. LOOP ID Reference NAME Values Notes Comments None ISA ISA Interchange Control Header ISA05 Interchange ID Qualifier ZZ ZZ Mutually defined ISA06 Interchange Sender ID Submitter ID This is the Submitter ID assigned by UnitedHealthcare. ISA08 Interchange Receiver ID 87726 (claims) UnitedHealthcare Payer ID -Right pad as needed with spaces to 15 characters. 5.2 GS-GE EDI transactions of a similar nature and destined for one trading partner may be gathered into a functional group, identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS segment marks the beginning of a functional group. There can be many functional groups within an interchange envelope. The number of GS GE functional groups that exist in a transmission may vary. Page 11 of 18 The below table represents only those fields that UnitedHealthcare requires a specific value in or has additional guidance on what the value should be. The table does not represent all of the fields necessary for a successful transaction; the TR3 should be reviewed for that information. LOOP ID Reference NAME Values Notes Comments None GS Functional Group Header Required Header GS03 Application Receiver s Code 87726 (claims) UnitedHealthcare Payer ID Code GS08 Version Release Industry Identifier Code 005010X222A1 Version expected to be received by UnitedHealthcare 5.3 ST-SE The beginning of each individual transaction is identified using a transaction set header segment (ST). The end of every transaction is marked by a transaction set trailer segment (SE). For real time transactions, there will always be one ST and SE combination. An 837 file can only contain 837 transactions. The below table represents only those fields that UnitedHealthcare requires a specific value in or has additional guidance on what the value should be. The table does not represent all of the fields necessary for a successful transaction; the TR3 should be reviewed for that information. LOOP ID Reference NAME Codes Notes Comments None ST Transaction Set Header Required Header ST03 Implementation Convention Reference 005010X222A1 Version expected to be received by UnitedHealthcare 5.4 CONTROL SEGMENT HIERARCHY ISA - Interchange Control Header segment GS - Functional Group Header segment ST - Transaction Set Header segment First 837 Transaction SE - Transaction Set Trailer segment ST - Transaction Set Header segment Second 837 Transaction SE - Transaction Set Trailer segment ST - Transaction Set Header segment Third 837 Transaction SE - Transaction Set Trailer segment GE - Functional Group Trailer segment IEA - Interchange Control Trailer segment 5.5 CONTROL SEGMENT NOTES The ISA data segment is a fixed length record and all fields must be supplied. Fields not populated with actual data must be filled with space. Page 12 of 18 1. The first element separator (byte 4) in the ISA segment defines the element separator to be used through the entire interchange. 2. The ISA segment terminator (byte 106) defines the segment terminator used throughout the entire interchange. 3. ISA16 defines the component element 5.6 FILE DELIMITERS UnitedHealthcare requests that you use the following delimiters on your 270 file. If used as delimiters, these characters (: ) must not be submitted within the data content of the transaction sets. Please contact UnitedHealthcare if there is a need to use a delimiter other than the following: 1. Data Element: The recommended data element delimiter is an asterisk ( ) 2. Data Segment: The recommended data segment delimiter is a tilde ( ) 3. Component Element: ISA16 defines the component element delimiter is to be used throughout the entire transaction. The recommended component-element delimiter is a colon (:) 4. Repetition Separator: ISA11 defines the repetition separator to be used throughout the entire transaction. The recommended repetition separator is a caret ( ) PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 6.1 ELECTRONIC CLAIM SUBMISSION GUIDELINES Following these guidelines will help you submit most of your claims electronically, without paper forms or attachments. Services Guidelines Allergy Procedure Codes Instead of submitting medical notes, use the EDI Notes Field to indicate number of doses, vials or injections as well as the dose schedule. Corrected Claims Most corrected claims can be sent electronically. Submit a corrected claim as an 837 transaction with frequency code 7 to indicate replacement of a previous claim (Loop 2300 CLM05-3). Go to UHCprovider.com ediclaimtips for more information. If unable to submit with EDI, submit as a claim reconsideration in the claimsLink tool. Learn more online: https: www.uhcprovider.com en claims-payments- billing claimslink-self-service-tool.html In Network Out of Network Under the capitated delegated agreement with UnitedHealthcare to support Medicare Advantage EOB for Part C, all encounter submissions must reflect whether the services provided to the member is in network or out of network. Any finalized claim or encounter that contains a service that is out of network should be reported using claim adjustment reason code (CARC) 242 Services Not Provided by Network Primary Care Provider, at the service line level. Interest Payments Under the capitated delegated agreement with UnitedHealthcare to submit encounter data, any finalized claim in part or in its entirety that contains interest payments must display these payments using a claim adjustment reason code (CARC) 225 Payment or Interest Paid by Payer. This code should only be used for plan to plan encounter reporting. According to Section 1.1.1.1 of the 005010X222A1, balancing to the claim payment involves the subtraction of adjustments from the service line payment total. A positive dollar amount for interest would reduce the payment of the claim. A negative dollar amount would increase the payment on the claim. As a result, reporting the payment of interest by a prior payer in the 837 would require a negative dollar amount in order to balance. Page 13 of 18 Laboratory Services When performed in the office on an urgent basis, use modifier ST in the modifier field. Lifetime Events A lifetime event is described as a medical procedure that can only occur once in a lifetime. Such events include but are not limited to Hysterectomy, Prostatectomy, Appendectomy, and Amputations, etc. Lifetime events must be reported with a unit value of only 1. Medicare Primary claims When Medicare is primary, check your Medicare Explanation of Benefits (EOB) for Code MA-18 to indicate the claim has been forwarded to the secondary carrier. If it hasn t been forwarded or has been sent to the wrong carrier, then submit the claim and the EOB Coordination of Benefits (COB) information electronically. More information on Medicare Crossover is online in the Secondary COB or Tertiary Claims section: https: www.uhcprovider.com en resource- library edi edi-quick-tips-claims.html Participating Physician Covering Primary Care Physician (PCP) When a UnitedHealthcare participating physician is covering for a PCP, use the EDI Notes Field to indicate Covering for Dr. X instead of submitting an attachment. Rejected Claims Claim rejections that appear on clearinghouse reports have not been accepted by UnitedHealthcare and should be corrected and resubmitted electronically. Required Member Cost Share Revenue Reporting For Commercial and Medicare Advantage plans, UnitedHealthcare requires1 contracted providers to submit current, complete and accurate encounter data including member cost share revenue weekly in order to effectively track member cost share. UnitedHealthcare welcomes and encourages your encounter submissions more frequently than weekly (e.g., twice a week, daily). Greater encounter submission frequency allows us to more effectively administer products where member cost share administration is essential. 1Centers for Medicare Medicaid Services mandate for Maximum Allowable Out-of-Pocket Cost Amount for Medicare Parts A and B Services 75 FR 19709, effective Jan. 1, 2011 Secondary Claims When another commercial insurance plan is primary and UnitedHealthcare is secondary, the secondary claim can be submitted electronically. Information from the primary payer s EOB COB can be included in the electronic claim. More information on submitting electronic Secondary COB or Tertiary Claims, including COB Electronic Claim Requirements and Specifications, is online: https: www.uhcprovider.com en resource-library edi edi-quick-tips-claims.html Sequestration As required by federal law under a sequestration order dated March 1, 2013, Medicare Fee-For-Service claims with dates of service or dates of discharge on or after April 1, 2013, incur a two percent reduction in Medicare payment. Source: Center for Medicare and Medicaid Services. Under the capitated delegated agreement with UnitedHealthcare to submit encounter data, any finalized claim in part or in entirety that contains a reduction in payment due to sequestration should be reported to UnitedHealthcare using claim adjustment reason code (CARC) 253 Sequestration. Sequestration reduction should be presented at the service line level. Tracers or Re-Bills It isn t necessary to send a paper claim backup for a claim sent electronically: Please allow 20-30 business days for your claim(s) to be processed. To avoid duplicate claim denials, check the status of your claim as a 276 277 EDI transaction or using Link instead of submitting a tracer. Unspecified CPT and HCPCS codes Unlisted and Unspecified Service or Procedure Codes can be submitted an electronic claim, however, UnitedHealthcare will need to review medical notes in order to process these claims. Attachments requested can be uploaded using the claimsLink app. More information on submitting unspecified codes on an electronic claim is online: https: www.uhcprovider.com en resource-library edi edi-quick-tips-claims.html Page 14 of 18 Voids and Replacements A replacement encounter should be sent to UnitedHealthcare when an element of data on the encounter was either not previously reported or when there is an element of data that needs to be corrected. A replacement encounter should contain a claim frequency code of 7 in Loop 2300 CLM05-3 segment. A void encounter should be sent to UnitedHealthcare when the previously submitted encounter should be eliminated. A void encounter must match the original encounter with the exception of the claim frequency type code and the payer assigned claim number. A void encounter should not contain negative values within the encounter. It should contain a claim frequency code of 8 in Loop 2300 CLM05-3 segment. The replacement or void encounter is required to be submitted with the Original Reference Number (Payer Claim Control Number) in Loop 2300 REF segment. REF01 must be F8 and REF 02 must be the Original Reference Number. If the required information in Loop 2300 REF01 and REF02 is not submitted, the encounter will reject back to the submitter. 6.2 VALIDATION OF CLAIMS UnitedHealthcare applies two levels of editing to inbound HIPAA 837 files and claims: 1. Level 1 HIPAA Compliance: Claims passing Level 1 Compliance are assigned a UnitedHealthcare Payer Claim Control Number and are accepted for front end processing. 2. Level 2 Front End Validation: Member match Provider match WEDI SNIP Level 1-5 validation Level 1 HIPAA Compliance: 3. Encounters or claims passing front end validation are accepted into the UnitedHealthcare adjudication system for processing. 4. Encounters or claims that do not pass front end validation will be rejected and returned to the submitter. 5. Institutional Claims with the value 'II' (Standard Unique Health Identifier) in Subscriber Name, field NM108 will be rejected by UnitedHealthcare. If this situational segment is used, a value of MI should be sent. Note: Mandate date is still not decided for using the Standard Unique Health Identifier. ACKNOWLEDGEMENTS AND REPORTS 7.1 ACKNOWLEDGEMENTS TA1 Transaction Acknowledgement This file informs the submitter that the transaction arrived and provides information about the syntactical quality of the Envelope of the submitted X12 file. UnitedHealthcare real-time will only respond with a TA1 when the X12 contains Envelope errors. The submitted 837 will need to be corrected and resubmitted. 999 Functional Acknowledgement This file informs the submitter that the transaction arrived and provides information about the syntactical quality of the Functional Groups in a submitted X12 file. UnitedHealthcare will respond with a 999 when the X12 contains Functional errors. The submitted 837 will need to be corrected and resubmitted. Page 15 of 18 277PRE This file informs the submitter with more detail about why the claim failed validation. The 277PRE is generated when claims in the batch file failed Level 1 validation. If no claims failed Level 1 validation, then the 277PRE is not created. 277ACK This file informs the submitter of the disposition of their claims through Level 2 Front End Validation, it reports both accepted and rejected claims. 7.2 REPORT INVENTORY There are no known applicable reports. TRADING PARTNER AGREEMENTS 8.1 TRADING PARTNERS An EDI Trading Partner is defined as any UnitedHealthcare customer (provider, billing service, software vendor, clearinghouse, employer group, financial institution, etc.) that transmits to or receives electronic data from UnitedHealth Group. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. TRANSACTION SPECIFIC INFORMATION The table below represents only those fields that UnitedHealthcare requires a specific value in or has additional guidance on what the value sent in the response means. The table does not represent all of the fields that will be returned in a successful transaction. The TR3 should be reviewed for that information. Loop Reference Name Values Notes Comments None BHT Beginning of Hierarchical Transaction BHT02 Transaction Set Purpose Code 00 00 Original 18 Reissue Code identifying the purpose of the transaction. BHT06 Transaction Type Code CH CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. 1000A Submitter Detail 1000A NM1 Submitter Name Required Segment 1000A NM109 Identification Code ETIN Federal Tax ID of the submitter. This number should be identical to the ISA06 and GS02 Federal Tax ID. 1000B Receiver Detail 1000B NM1 Receiver Name Required Segment 1000B NM103 Name Last or Organization Name UNITEDHEALTHCARE (BHT06 CH) Receiver Name (Organization) Page 16 of 18 1000B NM108 Identification Code Qualifier 46 ETIN Code 1000B NM109 Identification Code 87726 (claims) UnitedHealthcare Payer ID 2000B Subscriber Information 2000B HL Subscriber Hierarchical Level UnitedHealthcare patients cannot be identified within Loop 2010CA. If a UnitedHealthcare patient can be uniquely identified by a unique Member Identification Number, then the patient is considered the subscriber and is identified at this level. When the patient is the subscriber, loops 2000C and 2010Ca are not sent. 2010BA Subscriber Name 2010BA NM1 Subscriber Name 2010BA NM108 Identification Code Qualifier MI MI is the only valid value at this time. Claims received with value II will be rejected. 2010BB Payer Name 2010BB NM1 Payer Name 2010BB NM103 Name Last or Organization Name UNITEDHEALTHCARE (BHT06 CH) 2010BB NM108 Identification Code Qualifier PI PI Payer Identifier 2010BB NM109 Identification Code 87726 (claims) 2010BB Billing Provider Secondary Identifier 2010BB REF Billing Provider Secondary Identifier Required Segment 2010BB REF02 Reference Identification 2300 Claim Information 2300 CLM Claim Information 2300 DTP Date-Initial Treatment Submit initial treatment 2300 DTP Date-Admission Submit Admission Date for Emergency Room (ER) visits when the patient is admitted from the ER. 2300 Health Care Information Codes 2300 HI Health Care Diagnosis Code 2300 HI01-1 Code List Qualifier Code ABK 2300 HI02-1 to HI12-1 Code List Qualifier Code ABF 2400 Professional Services 2400 SV1 Professional Service 2300 SV103 Unit or Basis for Measurement Code MJ Submit code MJ when reporting anesthesia minutes in Loop 2400 SV104 Page 17 of 18 2300 SV104 Quantity Units: Submit a maximum unit quantity of 999 per occurrence of Loop 2400 SV1. When unit quantity is greater than 999, submit multiple occurrences with up to 999 units per occurrence. Minutes: Submit quantity as minutes for time based anesthesia services using MJ qualifier in Loop 2400 SV103. 2400 Test Results 2400 MEA Test Results 2400 MEA01 Measurement Reference ID Code TR for Hematocrit Hematocrit (HCT) test level is requested on all claims with services for erythropoietin (EPO). 2400 MEA02 Measurement Qualifier R2 for Hematocrit To indicate test results being reported for Hematocrit 2400 MEA03 Measurement Value Submit Hematocrit test result value 2400 Other Information 2400 PS1 Purchased Service Information Submit Purchased Service Information when the contract between UnitedHealthcare and the provider indicates reimbursement based on a percentage of the invoice. 2400 HCP Line Pricing Repricing Information Submit line pricing for repriced claims. 2410 LIN Drug Identification Submit NDC for all unlisted injectable drugs and for other injectable drugs when required per the contract between UnitedHealthcare and the provider. APPENDECIES 10.1 IMPLEMENTATION CHECKLIST The implementation check list will vary depending on your clearinghouse connection. A basic check list would be to: 1. Register with trading partner 2. Create and sign contract with trading partner 3. Establish connectivity 4. Send test transactions 5. If testing succeeds, proceed to send production transactions 10.2 FREQUENTLY ASKED QUESTIONS 1. Does this Companion Guide apply to all UnitedHealthcare payers and payer IDs? No. It s applicable to UnitedHealthcare Commercial (87726), UnitedHealthcare Community Plan (87726 plus other payer IDs), UnitedHealthcare Medicare and Retirement (87726), UnitedHealthcare Oxford (06111), UnitedHealthcare Vision (00773), UnitedHealthcare West (87726) and Medica (94265). 2. How does UnitedHealthcare support, monitor and communicate expected and unexpected connectivity outages? Our systems do have planned outages. We will send an email communication for scheduled and unplanned outages. 3. If an 837 is successfully transmitted to UnitedHealthcare, are there any situations that would result in no response being sent back? Page 18 of 18 No. UnitedHealthcare will always send a response. Even if UnitedHealthcare systems are down and the transaction cannot be processed at the time of receipt, a response detailing the situation will be returned. 10.3 FILE NAMING CONVENTIONS Node Description Value ZipUnzip_ResponseType_ Batch ID _ Submitter ID _ DateTimeStamp.RES ZipUnzip Responses will be sent as either zipped or unzipped depending on how UnitedHealthcare received the inbound batch file N - Unzipped Z - Zipped ResponseType Identifies the file response type 999 Implementation Acknowledgement Batch ID Response file will include the batch number from the inbound batch file specified in ISA13 ISA13 Value from Inbound File Submitter ID The submitter ID on the inbound transaction must be equal to ISA06 value in the Interchange Control Header within the file ISA08 Value from Inbound File DateTimeStamp Date and time format is in the next column (time is expressed in military format as CDT CST) MMDDYYYYHHMMSS | /kaggle/input/edi-db-835-837/EDI-837P-CG-005010X222A1.pdf | 1cad7d28e6149a1dbd60806e0461b980 | 1cad7d28e6149a1dbd60806e0461b980_0 |
Page 1 of 12 Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X221A1 Health Care Claim Payment Advice (835) Companion Guide Version Number 4.1 3 27 2024 Page 2 of 12 CHANGE LOG Version Release Date Changes 1.0 12 10 2010 Created 835 Companion Guide based on version 5010. 2.0 09 25 2017 Changed Clearinghouse name from Ingenix to OptumInsight; Reformatted entire document and updated various sections with current information, including hyperlinks and contacts. 3.0 09 28 2018 Updated Intelligent EDI hyperlink in section 2.3 and ERA Payer List hyperlink in section 4.1 4.0 05 11 2020 Updated Section 2.2 Clearinghouse Connections and Section 4.1 EDI Support 4.1 08 21 2020 Updated Sections 2.1, 3.4, 3.5, 4.3 4.2 3 27 2024 Updated Logo Page 3 of 12 PREFACE This companion guide (CG) to the Technical Report Type 3 (TR3) clarifies and specifies the data content when exchanging transactions electronically with UnitedHealthcare. Transactions based on this companion guide used in tandem with the TR3, also called 835 Health Care Claim Payment Advice ASC X12 (005010X221A1), are compliant with both X12 syntax and related guides. This Companion Guide is intended to convey information that is within the framework of the TR3 adopted for use under HIPAA. The companion guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the TR3. Page 4 of 12 Table of Contents CHANGE LOG......................................................................................................................................... 2 PREFACE............................................................................................................................................... 3 1. INTRODUCTION.......................................................................................................................... 6 1.1 SCOPE................................................................................................................................. 7 1.2 OVERVIEW........................................................................................................................... 7 1.3 REFERENCE.......................................................................................................................... 7 1.4 ADDITIONAL INFORMATION.................................................................................................. 7 2. GETTING STARTED...................................................................................................................... 7 2.1 EXCHANGING TRANSACTIONS WITH UNITEDHEALTHCARE......................................................... 7 2.2 CLEARINGHOUSE CONNECTION.............................................................................................. 7 2.3 DIRECT CONNECTION.................................................................. Error! Bookmark not defined. 2.4 LINK.................................................................................................................................... 8 3. CONNECTIVITY AND COMMUNICATION PROTOCOLS...................................................................... 8 3.1 PROCESS FLOW.................................................................................................................... 8 3.2 TRANSMISSION ADMINISTRATIVE PROCEDURES...................................................................... 8 3.3 RE-TRANSMISSION PROCEDURES........................................................................................... 8 3.4 COMMUNICATION PROTOCOL SPECIFICATIONS....................................................................... 9 3.5 PASSWORDS........................................................................................................................ 9 4. CONTACT INFORMATION............................................................................................................. 9 4.1 EDI SUPPORT....................................................................................................................... 9 4.2 PROVIDER SERVICES............................................................................................................. 9 4.3 APPLICABLE WEBSITES EMAIL.............................................................................................. 10 5. CONTROL SEGMENTS ENVELOPES.............................................................................................. 10 5.1 ISA-IEA.............................................................................................................................. 10 5.2 GS-GE................................................................................................................................ 10 5.3 ST-SE................................................................................................................................. 10 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS..................................................................... 10 6.1 CLAIM OVERPAYMENT RECOVERY........................................................................................ 10 6.2 SECONDARY AND TERTIARY PAYMENT REPORTING................................................................ 11 6.3 ENCOUNTER CLAIMS........................................................................................................... 11 6.4 835 ENROLLMENTS............................................................................................................. 11 6.5 LOST CHECK REPORTING...................................................................................................... 11 7. ACKNOWLEDGEMENTS AND REPORTS........................................................................................ 11 Page 5 of 12 7.1 REPORT INVENTORY........................................................................................................... 11 8. TRADING PARTNER AGREEMENTS.............................................................................................. 12 8.1 TRADING PARTNERS........................................................................................................... 12 9. TRANSACTION SPECIFIC INFORMATION....................................................................................... 12 Page 6 of 12 1. INTRODUCTION This section describes how Technical Report Type 3 (TR3), also called 835 Health Care Claim Payment Advice ASC X12 (005010X221A1), adopted under HIPAA, will be detailed with the use of a table. The tables contain a row for each segment that UnitedHealth Group has included, in addition to the information contained in the TR3s. That information can: 1. Limit the repeat of loops, or segments 2. Limit the length of a simple data element 3. Specify a sub-set of the TR3 s internal code listings 4. Clarify the use of loops, segments, composite and simple data elements 5. Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with UnitedHealthcare In addition to the row for each segment, one or more additional rows are used to describe UnitedHealthcare s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The table below specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. The table contains a row for each segment that UnitedHealthcare has included, in addition to the information contained in the TR3s. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides: Page Loop ID Reference Name Codes Length Notes Comments 71 1000A NM1 Submitter Name This type of row always exists to indicate that a new segment has begun. It is always shaded at 10 and notes or comment about the segment itself goes in this cell. 114 2100C NM109 Subscriber Primary Identifier 15 This type of row exists to limit the length of the specified data element. 114 2100C NM108 Identification Code Qualifier MI This type of row exists when a note for a particular code value is required. For example, this note may say that value MI is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it. 184 2300 HI Principal Diagnosis Code 2300 HI01-2 Reference Identifier Qualifier BK This row illustrates how to indicate a component data element in the Reference column and also how to specify that only one code value is applicable. Page 7 of 12 1.1 SCOPE This document is to be used for the implementation of the TR3 HIPAA 5010 835 Health Care Claim Payment Advice (referred to 835 claim payment in the rest of this document) for the purpose of reporting claim payment information from UnitedHealthcare. This document is to be used as a Companion Guide (CG) to the 835 Health Care Claim Payment Advice ASC X12 (005010X221A1) Implementation Guide, also referred to as Technical Report Type 3 (TR3), not intended to replace the TR3. 1.2 OVERVIEW This CG will replace, in total, the previous UnitedHealthcare CG versions for Health Care Claim Payment Advice and must be used in conjunction with the TR3 instructions. The CG is intended to assist you in implementing 835 claim payment transactions that meet UnitedHealthcare processing standards, by identifying pertinent structural and data related requirements and recommendations to more effectively complete EDI transactions with UnitedHealthcare. Updates to this companion guide will occur periodically and new documents will be posted in the Companion Guides section of our resource library and distributed to all registered trading partners with reasonable notice, or a minimum of 30 days, prior to implementation. In addition, all trading partners will receive an email with a summary of the updates and a link to the new documents posted online. 1.3 REFERENCE For more information regarding the ASC X12 Standards for Electronic Data Interchange 276 277 Health Care Claim Payment Advice (005010X221A1) and to purchase copies of the TR3 documents, consult the Washington Publishing Company website. 1.4 ADDITIONAL INFORMATION The American National Standards Institute (ANSI) is the coordinator for information on national and international standards. In 1979 ANSI chartered the Accredited Standards Committee (ASC) X12 to develop uniform standards for electronic interchange of business transactions and eliminate the problem of non- standard electronic data communication. The objective of the ASC X12 committee is to develop standards to facilitate electronic interchange relating to all types of business transactions. The ANSI X12 standards is recognized by the United States as the standard for North America. Electronic Data Interchange (EDI) adoption has been proved to reduce the administrative burden on providers. 2. GETTING STARTED 2.1 EXCHANGING TRANSACTIONS WITH UNITEDHEALTHCARE UnitedHealthcare exchanges transactions with clearinghouses and direct submitters, also referred to as Trading Partners. Most transactions go through the Optum clearinghouse our managed gateway for EDI transactions. 2.2 CLEARINGHOUSE CONNECTION Physicians, facilities and health care professionals should contact their current clearinghouse vendor to discuss their ability to support the X12 Version 005010X221A1 835 claim payment transaction, as well as associated timeframes, costs, etc. This includes protocols for testing the exchange of transactions with UnitedHealthcare through your clearinghouse. Page 8 of 12 When utilizing a clearinghouse to receive the 835 claim payment transaction, contact the clearinghouse to facilitate the 835 enrollment process. Once the enrollment is complete, your software vendor or clearinghouse will provide instructions on how to download or view the 835 transaction. Go to UHCprovider.com ediconnect for more information on clearinghouses and Optum solutions. 2.3 LINK Download the 835 claim payment file from the Electronic Payments Statements (EPS) app in LINK. Enrollment in EPS is required for this capability and allows you to receive Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) for UnitedHealthcare Commercial, UnitedHealthcare Community Plan, UnitedHealthcare Medicare Solutions and UnitedHealthcare Oxford. More information about EPS including enrollment and assistance is available online. 3. CONNECTIVITY AND COMMUNICATION PROTOCOLS 3.1 PROCESS FLOW 3.2 TRANSMISSION ADMINISTRATIVE PROCEDURES The Direct Connection process can be used in batch mode (FTP or SFTP) using Web Services. Using these types of connections will allow you to either choose a manual process or automate your system. 3.3 RE-TRANSMISSION PROCEDURES Page 9 of 12 Trading Partners can request re-transmission of the entire 835 file by contacting EDI Support using our EDI Transaction Support Form, sending an email to supportedi uhc.com or calling 800-842-1109. The 835 file will be routed through the Trading Partner s regular connectivity path. Please note the re-transmission is the entire 835 file, not a specified 835 contained within a file. Physicians and health care professionals that do not have a direct connection with UnitedHealthcare will need to contact the entity they are receiving the 835 file from to discuss how to receive a re-transmission. 3.4 COMMUNICATION PROTOCOL SPECIFICATIONS Clearinghouse Connection: Physicians and health care professionals should contact their current clearinghouse for communication protocols with UnitedHealthcare. Optum Connection: For communication protocols using Optum Intelligent EDI, please contact Optum at 866-367-9778, send an email to IEDIsales optum.com or visit their website 3.5 PASSWORDS 1. Clearinghouse Connection: Physicians and health care professionals should contact their current clearinghouse vendor to discuss password policies. 2. CAQH CORE Connectivity: Optum is acting as a CORE connectivity proxy for UnitedHealthcare 835 health claim payment transactions. For information regarding passwords, please contact Optum. 4. CONTACT INFORMATION 4.1 EDI SUPPORT Most questions can be answered by referring to the EDI section of our resource library on UHCprovider.com. View the EDI 835: Electronic Remittance Advice (ERA) page for information specific to 835 health claim payment transactions. Enroll in Electronic Payments and Statements to receive your 835 files. Visit UHCprovider.com contacts for 835 EDI Support. If you have questions related to submitting transactions through a clearinghouse, please contact your clearinghouse or software vendor directly. 4.2 PROVIDER SERVICES Provider Services should be contacted at 877-842-3210 instead of EDI Support if you have questions regarding the details of a member s benefits. Provider Services is available Monday - Friday, 7 am - 7 pm in the provider s time zone. Page 10 of 12 4.3 APPLICABLE WEBSITES EMAIL CAQH CORE: http: www.caqh.org Companion Guides: https: www.uhcprovider.com en resource-library edi edi-companion-guides.html UnitedHealthcare EDI Support: UHCprovider.com contacts UnitedHealthcare EDI website: https: www.uhcprovider.com en resource-library edi.html Optum: https: www.optum.com Optum Intelligent EDI - https: www.optum.com business solutions provider claims-management- strategy edi intelligent-edi.html Washington Publishing Company - http: www.wpc-edi.com reference 5. CONTROL SEGMENTS ENVELOPES 5.1 ISA-IEA Transactions transmitted during a session or as a batch are identified by an interchange header segment (ISA) and trailer segment (IEA) which form the envelope enclosing the transmission. Each ISA marks the beginning of the transmission (batch) and provides sender and receiver identification. UnitedHealthcare uses the following delimiters on your 835 file: 1. Data Element: The first element separator following the ISA will define what Data Element Delimiter is used throughout the entire transaction. The Data Element Delimiter is an asterisk ( ). 2. Segment: The last position in the ISA will define what Segment Element Delimiter is used throughout the entire transaction. The Segment Delimiter is a tilde ( ). 3. Component-Element: Element ISA16 will define what Component-Element Delimiter is used throughout the entire transaction. The Component-Element Delimiter is a colon (:). 5.2 GS-GE EDI transactions of a similar nature and destined for one trading partner may be gathered into a functional group, identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS segment marks the beginning of a functional group. There can be many functional groups within an interchange envelope. 5.3 ST-SE The beginning of each individual transaction is identified using a transaction set header segment (ST). The end of every transaction is marked by a transaction set trailer segment (SE). 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 6.1 CLAIM OVERPAYMENT RECOVERY Claim Overpayment Recovery occurs when UnitedHealthcare identifies that a prior processed claim was overpaid. To recoup the overpayment, UNET Business will follow the steps outlined in method three provided in section 1.10.2.17 (Claim Overpayment Recovery) of the ASC X12 005010X221A1 835 implementation guide. COSMOS business follows a combination of methods. Page 11 of 12 6.2 SECONDARY AND TERTIARY PAYMENT REPORTING UnitedHealthcare will report secondary and tertiary payment claims in the 835 transaction. On UNET, professional (physician) claim reporting will provide the payment information at the service line level with institutional claims reporting payment information at the claim level. No service level detail will be reported on institutional secondary and tertiary payment claims. Section 10.3 (Transaction Examples) provides examples of professional and institutional secondary claims reporting in the 835 transactions. On COSMOS, professional and institutional claims report payment information at the service line level. 6.3 ENCOUNTER CLAIMS UnitedHealthcare UNET 835s do not provide capitation payments in the 835 transaction, but will provide the Encounter claims processed under the capitation agreement. Encounter claims will be reported in the 835 transaction along with claims that fall outside of the capitation agreement. Section 10.3 (Transaction Examples) provides examples of encounter claim reporting in the 835 transaction. COSMOS does not report capitation payments or encounter claims in the 835 transaction. 6.4 835 ENROLLMENTS The 835 transaction enrollment registration will be done at the Federal Tax Identification Number level. Registrations for 835 at levels lower than the Federal Tax Identification Number do not currently exist. 6.5 LOST CHECK REPORTING Occasionally, the re-association process identifies a received remittance advice without the associated payment. This could result from situations like a lost check or misdirected EFT. Since there is no problem with the remittance information, the remittance advice will not be recreated. To handle the lost payment, COSMOS will follow the method 2 described in Section 1.10.2.3.1 (Lost and Reissued Payments) of the ASC X12 005010X221A1 835 Implementation Guide. 7. ACKNOWLEDGEMENTS AND REPORTS 7.1 REPORT INVENTORY No 835 reporting is available at this time. Page 12 of 12 8. TRADING PARTNER AGREEMENTS 8.1 TRADING PARTNERS An EDI Trading Partner is defined as any UnitedHealthcare customer (provider, billing service, software vendor, clearinghouse, employer group, financial institution, etc.) that transmits to, or receives electronic data from UnitedHealth Group. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. For example, a Trading Partner Agreement may specify among other things, the roles and responsibilities of each party to the agreement in conducting standard transactions. 9. TRANSACTION SPECIFIC INFORMATION UnitedHealthcare has put together the following grid to assist you in designing and programming the information provided in 835 transactions. This Companion Guide is meant to illustrate the data provided by UnitedHealthcare for successful posting of Health Care Claim Payment Advice transactions. The table contains a row for each segment that UnitedHealthcare has something additional, over and above, the information in the implementation guide. That information can: 1. Limit the repeat of loops or segments 2. Limit the length of a simple data element 3. Specify a sub-set of the implementation guide s internal code listings 4. Clarify the use of loops, segments, composite and simple data elements 5. Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with UnitedHealthcare All segments, data elements and codes supported in the ASC X12N 005010X221A1 835 Implementation Guide are acceptable, however, all data may not be used in the processing of this transaction by UnitedHealthcare for an 835 transaction. | /kaggle/input/edi-db-835-837/EDI-835-Companion-Guide-005010X221A1.pdf | ed861059f7c9d03e09383db0b383d447 | ed861059f7c9d03e09383db0b383d447_0 |
837 Health Care Claim Companion Guides Version 2.8 January, 2024 i 837 Health Care Claim Companion Guides Version 2.8 January, 2024 For use with ASC X12N 837 Health Care Professional and Institutional Transactions Set Implementation Guides and Addenda (Version HIPAA 5010) www.carelonbehavioralhealth.com 837 Health Care Claim Companion Guides Version 2.8 January, 2024 ii CONTENTSIntroduction......................................................................................................................................................1 Audie nce and ContactInformation........................................................................................................... 4..........................................................................................................................2 Set-UpProcess Infor mation.........................................................................................................................6 5 SupportedTransactionsandLimitations................................................................................................8 3.2. Submitter Form Information............................................................................................7 4.1. Inbound Transactions Supported Testing..............................................................................................................................................................12 4.3. Delimiters Supported......................................................................................................9 4.4. Maximum Limitations.................................................................................................... 10 5.1. Testing Workflow.......................................................................................................... 13 5.2. Testing Intro................................................................................................................. 13 5.3. Validation Specifications............................................................................................... 14 Imple mentation............................................................................................................................................. 17 5.6. Trading Partner Acceptance Testing Specifications and Requirements......................... 15 6.1. Interchange Control Header Specifications................................................................... 18 Profe ssional Claims TransactionSpecifications.................................................................................24 6.4. Functional Group Trailer Specifications......................................................................... 23 InstitutionalClaimTransactionSpecifications...................................................................................46 7.1. 837 Professional Claim Transaction Specifications.......................................................... 25 8.1. 837 Institutional Claim Transaction Specifications......................................................... 41 837 Health Care Claim Companion Guides Version 2.8 January, 2024 iii VERSION CHANGES DATE Version 1.0 DRAFT Sept. 2016 Version 1.1-1.5 Format changes and Final Version Sept. 2016 Version 1.6 Format changes and Final Version March 2017 Version 1.7 Add Instructions for Atypical Providers April 2017 Version 1.8 Format changes and corrections April 2017 Version 1.9 Format changes and corrections May 2017 Version 2.0 Added Section 4.5 - Character Sets Supported (Page 3) Removed hard-coded GS03 value from Section 6.3 Functional Group Header Specifications (Page 24) Added Code U and W as valid values for HI01-9 (Page 59) July 2017 Version 2.1 Format changes and corrections July 2017 Version 2.2 Correction to the description of 999 and 277CA generation by SNIP level. February 2018 Version 2.3 Section 5.6: Updated Passing Specifications May 2018 Version 2.4 Section 4.4 Updated to include business rules Section 5.4 Updated to exclude Snip 7 edits June 2018 Version 2.5 Updated Character Sets Supported June 2018 Version 2.6 Add Custom report response file details May 2021 Version 2.7 Add Custom report response file details November 2022 837 Health Care Claim Companion Guides Version 2.8 January, 2024 1 C h a p t e r 1 Introduction 1.1. Introduction 1.2. What is HIPAA? 1.3. Purpose 837 Health Care Claim Companion Guides Version 2.8 January, 2024 2 In an effort to reduce the administrative costs of health care across the nation, the Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996. This legislation requires that health insurance payers in the United States comply with the electronic data interchange (EDI) standards for health care, established by the Secretary of Health and Human Services (HHS). For the health care industry to achieve the potential administrative cost savings with EDI, standard transactions and code sets have been developed and need to be implemented consistently by all organizations involved in the electronic exchange of data. The ANSI X12N 837 The Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandates the establishment of national standards for electronic transmission of health data and ensuring privacy protection. The Administrative Simplification provisions of HIPAA, Title II, require the Department of Health and Human Services to establish national standards for electronic healthcare transactions and national identifiers for providers, health plans and employers. It also addresses the security and privacy of health data. Adopting these standards improves the efficiency and effectiveness of the nation s healthcare system by encouraging the widespread use of electronic data interchange in health care. The purpose of this document is to provide the information necessary to submit claims encounters electronically to Carelon Behavioral Health, Inc. This companion guide is to be used in conjunction with the ANSI X12N implementation guides. The information describes specific requirements for processing data within the payer s system. The companion guide supplements, but does not contradict or replace any requirements in the implementation guide. The implementation guides can be obtained from the Washington Publishing Company by calling 1-800-972-4334 or are available for download on their web site at www.wpc-edi.com. Other important websites: Workgroup for Electronic Data Interchange (WEDI) http: www.wedi.org United States Department of Health and Human Services (DHHS) http: aspe.hhs.gov Centers for Medicare and Medicaid Services (CMS) http: www.cms.gov National Council of Prescription Drug Programs (NCPDP) http: www.ncpdp.org National Uniform Billing Committee (NUBC) http: www.nubc.org Accredited Standards Committee (ASC X12) http: www.x12.org This Document has been prepared as the Carelon Behavioral Health (Carelon) specific Companion Guide to the ASC X12 Implementation Guide(s). The objectives of the Carelon Companion Guide are: To describe the process to become an EDI Trading partner with Carelon Behavioral Health To describe the processes to set up, test, and make operational a trading partner with Carelon Behavioral Health 837 Health Care Claim Companion Guides Version 2.8 January, 2024 3 To identify codes and data elements that are applicable to Carelon Behavioral Health. This document will be subject to revisions as new versions of the X12 837 Professional and Institutional Health Care Claim Transaction Set Implementation Guides are released. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 4 C h a p t e r 2 AudienceandContactInformation 2.1. Intended Audience 2.2. Contact Information 837 Health Care Claim Companion Guides Version 2.8 January, 2024 5 The intended audience for this document is the technical department team responsible for submitting electronic claims transactions to Carelon Behavioral Health. In addition, this information should be communicated and coordinated with the provider s billing office in order to ensure the required billing information is provided to their billing agent submitter. For HIPAA, 837 transactions, EDI, EDI Gateway, documentation and testing questions relating to Carelon, you can get answers by contacting any one of the following: EDI Helpdesk o Contact with EDI-related questions o 888-247-9311 o BH_EDI.Operations carelon.com Compliance Department o Contact for compliance legal concerns 781-994-7500 o BH_Compliance carelon.com 837 Health Care Claim Companion Guides Version 2.8 January, 2024 6 C h a p t e r 3 Set-UpProcessInformation 3.1. Trading Partner Submitter Forms 3.2. Submitter Form Information 837 Health Care Claim Companion Guides Version 2.8 January, 2024 7 Providers trading partners interested in submitting electronic claim transactions must complete one of the following forms supplied by Carelon: a) Provider Connect Online Services Account Request Form b) Billing Agent Online Services Request Form (Clearinghouse Form) These forms can be downloaded from Carelon s website at 3.2. or can be requested by contacting EDI Helpdesk at: Su bmitter Fo rm Information The Online Services Intermediary Authorization Form has to be completed by every provider who will be submitting via a clearinghouse. The Billing Agent Online Services Request Form would be completed by the clearinghouse on behalf of the healthcare provider(s). Complete the applicable form and return by FAX to 866-698-6032 or send by email to BH_EDI.Operations carelon.com When Carelon EDI receives the form, we will send you an email acknowledgement that indicates your setup has been completed with Carelon Helpdesk. This email will include the Carelon Submitter ID. A second email will be sent with the password attached. A submitter ID is assigned to each trading partner. You will utilize the submitter ID to access FileConnect, ProviderConnect, or SFTP for file transmission. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 8 C h a p t e r 4 Supported Transactions and Limitations 4.1. Inbound Transactions Supported 4.2. Response Transactions Supported 4.3. Delimiters Supported 4.4. Specific Limitations and Business Rules 837 Health Care Claim Companion Guides Version 2.8 January, 2024 9 4.1. InboundTransactionsSupported This section is intended to identify the type and version of the ASC X12 837 Health Care Claim transactions that Carelon will accept. X12 FILE TYPE FILE NAME PURPOSE SOURCE 837P 837 Professional Health Care Claim ASC X12N 837 (005010X222A1) 837 Professional Health Care Claim Trading Partner 837I 837 Institutional Health Care Claim ASC X12N 837 (005010X223A2) 837 Institutional Health Care Claim Trading Partner 4.2. ResponseTransactionsSupported This section is intended to identify the response transactions supported by Carelon. X12 FILE TYPE FILE NAME PURPOSE SOURCETURNAROUND FROM TIME OF SUBMISSION TA1 Interchange Acknowledgement Acknowledgement to verify transmission has been received Carelon Day of Submission 999 Functional Acknowledgement Acknowledgement to verify the syntactical accuracy of the file (accept, reject, or accepted with errors) Carelon Day of Submission 277CA Claims Acknowledgement Provides a claim level acknowledgement for all claims received Carelon 4 Business days Report Text file Custom Report Text file Only when invalid interchange ISA GS header segments are sent and HIPAA compliant TA1 file is not possible Carelon Day of Submission 4.3. DelimitersSupported 837 Health Care Claim Companion Guides Version 2.8 January, 2024 10 A delimiter is a character used to separate two data elements or sub-elements, or to terminate a segment. Delimiters are specified in the interchange header segment, ISA. The ISA segment is a 105-byte fixed length record. The data element separator is byte number 4; the component element separator is byte number 105; and the segment terminator is the byte that immediately follows the component element separator. Once specified in the interchange header, delimiters are not to be used in a data element value elsewhere in the transaction. Carelon requires utilizing the following default delimiters: DESCRIPTION DEFAULT DELIMITER Data element separator (Asterisk) Sub-element separator: (Colon) Segment Terminator (Tilde) Repetition Separator (Carat) 4.4. SpecificBusinessRulesandLimitations The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy of the looping structure is billing provider, subscriber, patient, claim level, and claim service line level. Each transaction set contains groups of logically related data in units called segments. The number of times a loop or segment may repeat in the transaction set structure is defined in the ASC X12 standard implementation guides. Some of these limitations are explicit, such as: The Claim Information loop (2300) is limited to 100 claims per patient. The system allows a maximum of one ISA IEA envelope per 837 file. The Service Line loop (2400) is limited to 50 service lines per professional claim or 50 service lines per institutional claim. The ST SE envelope can be a maximum of 5000 claims per transaction as long as the file does not exceed the maximum file size of 8MB. Atypical Providers This refers to providers who are not traditional health care providers, and therefore, do not have an NPI number assigned. Any claims submitted for services provided by atypical providers must have their Tax ID Number in 2010AA REF02 (REF01 EI or SY ), and their Medicaid or State assigned provider identifier in 2010BB REF02 (REF01 G2 ) in lieu of a Billing Provider NPI or 2310A REF02 (REF01 G2 ) in lieu of the Attending Provider NPI. Member and Provider Validation Review of member data to ensure the member is covered by a Carelon policy. Review of provider data to ensure the correct provider record in our database is used for claims adjudication Duplicate Claim Check When reviewing an Institutional claim, the following data elements are reviewed against claims received in the last 12 days: Patient control number, Member first and last name, Member address, Claim frequency code, Line level date of service, Revenue code, Procedure code, Total charge amount, and Billing provider NPI. When all data elements match the 837 Health Care Claim Companion Guides Version 2.8 January, 2024 11 claim will be rejected as an exact duplicate. When reviewing a Professional claim, the following data elements are reviewed against claims received in the last 12 days: Patient control number, Member first and last name, Member address, Claim frequency code, Line level data of service, Place of service, Procedure code, Total charge amount, and Billing provider NPI. NCCI Edits Using National Correct Coding Initiative guidelines we will review for the three possible edits: Procedure to procedure, Medically unlikely, and Add-on codes. 4.5. CharacterSetsSupported Carelon supports the Basic X12 Character Set: Uppercase Letters from A to Z Digits from 0 to 9 Special Characters: o! o o o o ( o ) o o o, o o. o o: o; o? o o (space) 837 Health Care Claim Companion Guides Version 2.8 January, 2024 12 C h a p t e r 5 Testing 5.1. Testing Workflow 5.2. Testing Intro 5.3. Validation Specifications 5.4. Compliance Testing Validation of Claims 5.5. National Provider Identifier Specifications 5.6. Trading Partner Acceptance Testing Specifications and Requirements 837 Health Care Claim Companion Guides Version 2.8 January, 2024 13 5.1. TestingWorkflow 5.2. TestingIntro Carelon requires testing for all direct submitters submitting 837P and 837I transactions. Please follow the appropriate format specifications listed in the specific data requirements and submission directions. Test files must be submitted using the secure protocols and submission methodology selected during the set- up process. Once a test Submitter ID is set up for a trading partner, the submitter can begin to send claims transactions for testing. In order to test, it is imperative that a technical contact be established at the provider submitter organization. This contact must be able to monitor, change and submit the 837P and 837I transaction files to Carelon. This contact should be familiar with 837P, 837I, TA1, 277CA, and 999 X12 file transactions. During the testing process, Carelon will examine submitted transactions for required formats and elements, and will provide feedback during the testing process. This testing stage will continue until testing satisfaction is achieved on both sides and Carelon receives sign-off from the trading partner. Carelon s testing procedures will validate the test file in its entirety. The entire file will either pass or fail validation. Carelon does not allow partial file submissions. If the file fails validation, a failure report will be provided explaining the failure messages for debugging. 837p 837I Testing Work-Flow Testing Production Start Contact Carelon Complete Carelon submitter Form Create 837p 837I test files Debug issues 837I 837P Trading Partner Sign--off Response Files Email Acknowledgement Send Files to Carelon No Yes Initiate Trading Partner Set-up process Process Submitter Form Send email withAssign submitter ID End Pass? Process Sign-off and Move Trading partner into production Carelon Health Options Trading Partner 837 Health Care Claim Companion Guides Version 2.8 January, 2024 14 Upon the completion of successful testing, Carelon will move the trading partner into our production system. The ID number must be used in all files submitted for production claims processing communicated and coordinated with the provider s billing office in order to ensure the required billing information is provided to their billing agent submitter. 5.3. ValidationSpecifications Initial validation is conducted at a batch level. If the batch file is not syntactically valid, the submitter will need to resubmit the corrected batch in its entirety. Secondary validation is conducted at a claim level. If claims are rejected on the claim level validation, the submitter will need to rebuild the corrected claims in a new batch and submit the new batch for validation. Do not resubmit the same batch after making the claim level corrections as this will cause any claims that have passed validation from the previous submission to duplicate in the system. 5.4. ComplianceTestingValidationofClaims The Workgroup for Electronic Data Interchange (WEDI) and the Strategic National Implementation Process (SNIP) have recommended seven types HIPAA compliance testing. Carelon will apply these validation edits during testing and production. Carelon applies the following edits to inbound HIPAA 837 files and claims: 1. SNIP Levels 1-6 Transaction Compliance Testing: SNIP-1: Integrity Testing This is testing the basic syntax and integrity of the EDI transmission to include: valid segments, segment order, element attributes, numeric values in numeric data elements, X12 syntax and compliance with X12 rules. SNIP-2: Requirement Testing This is testing for HIPAA Implementation Guide specific syntax such as repeat counts, qualifiers, codes, elements and segments. Also testing for required or intra-segment situational data elements and non-medical code sets whose values are noted in the guide via a code list or table. SNIP-3: Balance Testing This is testing the transaction for balanced totals, financial balancing of claims or remittance advice and balancing of summary fields. SNIP-4: Situational Testing This is testing of inter-segment situations and validation of situational fields based on rules in the Implementation Guide. SNIP-5: External Code Set Testing-This is testing of external code sets and tables specified within the Implementation Guide. This testing not only validates the code value but also verifies that the usage is appropriate for the particular transaction. SNIP-6: Product Type or Line of Service Testing This is testing that the segments and elements required for certain health care services are present and formatted correctly. This type of testing only applies to a trading partner candidate that conducts the specific line of business or product type. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 15 For more information on SNIP front end edits, the following sites can be referenced: Workgroup for Electronic Data Interchange (WEDI) http: www.wedi.org knowledge- center health-it-compliance Centers for Medicare and Medicaid Services (CMS) www.CMS.gov 5.5. NationalProviderIdentifierSpecifications Carelon Behavioral Health, in accordance with the HIPAA mandate will require covered entities to submit electronic claims with the NPI and taxonomy codes in the appropriate locations. The NPI is a standard provider identifier that will replace the provider numbers used in standard electronic transactions today and was adopted as a provision of HIPAA. The NPI Final Rule was published on January 23, 2004 and applies to all health care providers. Carelon Behavioral Health requires that all covered entities report their NPI prior to submitting electronic transactions containing an NPI. To update your provider NPI, please contact our National Provider Line at 800.397.1630. All electronic transactions for covered entities should contain the provider NPI, taxonomy code, employee identification number and zip code the 4-digit postal code in the appropriate loops. Additional information on NPI including how to apply for a NPI can be found on the Centers for Medicare and Medicaid Services (CMS) website at: https: www.cms.gov Regulations-and-Guidance Administrative- Simplification NationalProvIdentStand apply.html. 5.6. TradingPartnerAcceptanceTestingSpecificationsand Requirements Trading partners are encouraged to submit a test file prior to submitting claims electronically to Carelon Behavioral Health. To submit claims electronically, trading partners must obtain an ID Password from the Carelon Behavioral Health EDI Helpdesk. Based on the types of services provided, a trading partner may receive multiple submitter IDs. Test files will need to be submitted under all assigned submitter IDs. Trading partners who upgrade or change software are also encouraged to submit a test submission. Submitters will be notified via e-mail as to the results of the file validation. If the file failed validation, the e- mail message will provide explanations for the failure. Any error message that is not understood can be explained thoroughly by a Carelon Behavioral Health EDI Coordinator. After receiving notification that your test batch has passed validation, you will be asked to submit a sign- off document before submitting files to the production directories. Test files will go through SNIP Levels 1-6 Transaction Compliance Testing only. SNIP Level 7 Front-End Validation will be performed in production. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 16 Test sample: Provider and Member Data Samples 2 Files per Transaction Type (837I 837P) 10 Claims Per File Submit with dates of service within the past month Passing Specification: 2 Files per Transaction Type accepted (837I 837P) 10 out of 10 Claims per file passed front-end edits 100 Claim acceptance rate 837 Health Care Claim Companion Guides Version 2.8 January, 2024 17 C h a p t e r 6 Implementation 6.1. Interchange Control Header Specifications 6.2. Interchange Control Trailer Specifications 6.3. Functional Group Header Specifications 6.4. Functional Group Trailer Specifications 837 Health Care Claim Companion Guides Version 2.8 January, 2024 18 Seg Data Element Name Usage Comments Expected Value HEADER ISA INTERCHANGE R ISA01 Authorization Information Qualifier R Valid values: 03 Additional Data Identification Use 03 Additional Data Identification to indicate that a login ID will be present in ISA02. ISA02 Authorization Information R Information used for authorization. Use the Carelon Behavioral Health submitter ID as the login ID. Maximum 10 characters. ISA03 Security Information Qualifier R Valid values: 00 No Security Information Present 01 Password Use 01 value to indicate that a password will be present in ISA04. Use 00 value to indicate that no password will be present in ISA04. ISA04 Security Information R Additional security information identifying the sender. Use the Carelon Behavioral Health submitter ID password. Maximum 10 characters. ISA05 Interchange ID Qualifier R Use ZZ or Refer to the implementation guide for a list of valid qualifiers. ISA06 Interchange Sender ID R Usually Submitter ID out to 15 characters. Refer to the implementation guide specifications. ISA07 Interchange ID Qualifier R Use ZZ Mutually Defined. ISA08 Interchange Receiver ID R Use BEACON963116116 ISA09 Interchange Date R Date format YYMMDD. The date (ISA09) is expected to be no more than seven days before the file is received. Any date that does not meet this criterion may cause the file to be rejected. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 19 Seg Data Element Name Usage Comments Expected Value ISA10 Interchange Time R Time format HHMM. Refer to the implementation guide specifications. ISA11 Interchange Control Standards Identifier R Delimiter used to separate repeated occurrences of a simple data element or a composite data structure. This value must be different than the data element separator, component element, and the segment terminator. Valid value: Repetition Separator Use the value specified in the implementation guide. ISA12 Interchange Control Version Number R Use the current standard approved for the ISA IEA envelope. 00501 ISA13 Interchange Control Number R The interchange control number in ISA13 must be identical to the associated interchange trailer IEA02. This value is defined by the sender s system. If the sender does not wish to define a unique identifier, zero fill this element out to 9 Characters. ISA14 Acknowledgement Requested R This pertains to the TA1 acknowledgement. Valid values: 1 Interchange Acknowledgement Requested Use 1 Interchange Acknowledgement requested (TA1) ISA15 Usage Indicator R Valid values: P Production T Test The Usage Indicator should be set appropriately. Either can be used. ISA16 Component Element Separator R The delimiter must be a unique character not found in any of the data included in the transaction set. This element contains the delimiter that will be used to separate component data elements within a composite data structure. This value must be different from the data element separator and the segment terminator. Carelon Behavioral Health will accept any delimiter specified by the sender. The uniqueness of each delimiter will be verified.: (colon) usually 837 Health Care Claim Companion Guides Version 2.8 January, 2024 20 Seg Data Element Name Usage Comments Expected Value TRAILER IEA Interchange Control Trailer R IEA01 Number of Included Functional Groups Count the number of functional groups in the interchange Multiple functional groups may be sent in one ISA IEA envelope. This is the count of the GS GE functional groups included in the interchange structure. Limit the ISA IEA envelope to one type of functional group i.e.functional identifier code HC Health Care Claim (837). Segregate professional and institutional functional groups into separate ISA IEA envelopes. IEA02 Interchange Control Number The interchange control number in IEA02 must be identical to the associated interchange header value sent in ISA13. The interchange control number in IEA02 will be compared to the number sent in ISA13. If the numbers do not match the file will be rejected. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 21 Seg Data Element Name Usage Comments Expected Value HEADER GS Functional Group Header R GS01 Functional Identifier Code R Code identifying a group of application related transaction sets. Valid value: HC Health Care Claim (837) Use HC Health Care Claim GS02 Application Sender s Code R Submitter ID Provided by Carelon GS03 Application Receiver s Code R This field will identify how the file is received by Carelon Behavioral Health. Use BEACON963116116 GS04 Date R Date format CCYYMMDD Refer to the implementation guide for specifics. GS05 Time R Time format HHMM Refer to the implementation guide for specifics. GS06 Group Control Number R The group control number in GS06, must be identical to the associated group trailer GE02. Assigned number originated and maintained by the sender. Recommend that GS06 be unique within all transmissions over a period of time to be determined by the sender. GS07 Responsible Agency Code R Code identifying the issuer of the standard. Valid value: X -Accredited Standards Committee X12 Use X Accredited Standards Committee X12 837 Health Care Claim Companion Guides Version 2.8 January, 2024 22 GS08 Version Release Industry ID Code R Professional Addenda Approved for Publication by ASC X12: 005010X222A1 Institutional Addenda Approved for Publication by ASCX12: 005010X223A2 Use 005010X222A1 or 0051010X223A2 Other standards will not be accepted 837 Health Care Claim Companion Guides Version 2.8 January, 2024 23 Seg Data Element Name Usage Comments Expected Value TRAILER GE Functional Group Trailer R GE01 Number of Transaction Sets Included R Count of the number of transaction sets in the functional group. Multiple transaction sets may be sent in one GS GE functional group. Only similar transaction sets may be included in the functional group. GE02 Group Control Number R The group control number in GE02 must be identical to the associated functional group header value sent in GS06. The group control number in GE02 will be compared to the number sent in GS06. If the numbers do not match the entire file will be rejected. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 24 C h a p t e r 7 Professional Claims Transaction Specifications 7.1. 837 Professional Claim Transaction Specifications 837 Health Care Claim Companion Guides Version 2.8 January, 2024 25 837 Professional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value HEADER ST Transaction Set Header R ST01 Transaction Set Identifier Code R Use 837 Health Care Claim ST02 Transaction set control number R Assigned by sender. Must equal SE02 ST03 Transaction R Same as GS08 BHT Beginning of Hierarchical Transaction R BHT01 Hierarchical Structure Code R Valid values: 0019' Information Source, Subscriber, Dependent Use 0019 BHT02 Transaction Set Purpose Code R Valid values: 00' Original 18 Reissue Case where the transmission was interrupted and the receiver requests that the batch be sent again. Use 00 Original BHT03 Reference Identification R BHT03 is the number assigned by the originator to identify the transaction within the originator s business application system. Assigned by sender BHT04 Date R BHT04 is the date the transaction was created within the business application system. CCYYMMDD BHT05 Time R BHT05 is the time the transaction was created within the business application system. HHMMSSDD BHT06 Transaction Type Code R Separate claim and encounter data into two separate ISA IEA envelopes (files). CH is used for Claims RP is used for Encounters 837 Health Care Claim Companion Guides Version 2.8 January, 2024 26 Seg Data Element Name Usage Comments Expected Value LOOP 1000A SUBMITTER NM1 Submitter Name R NM101 Entity Identifier Code R Code identifier Code 41 is used for Submitter NM102 Entity Type Qualifier R 1 - Person 2 - Non-Person Entity 1 - Person 2 - Non-Person Entity NM103 Last name of Physician or organization name R Name Last or Organization Name Name Last or Organization Name NM104 First Name of Physician S Name First Only used if NM102 1 NM105 Middle Name of Physician S Name Middle Only used if NM102 1 NM108 ID code Qualifier R 46 Electronic Transmitter ID Number 46 Electronic Transmitter ID Number NM109 Submitter Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use the Carelon Behavioral Health assigned submitter ID Maximum 10 characters. LOOP 1000B - RECEIVER NM1 Receiver Name R NM101 Entity ID Code R 40 Receiver NM102 Entity Type Qualifier R 2 Non-Person Entity NM103 Receiver Name R Name Last or Organization Name Use CARELON BEHAVIORAL HEALTH, INC. NM108 ID Code R 46 Identification Code Qualifier NM109 Receiver Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use BEACON963116116 837 Health Care Claim Companion Guides Version 2.8 January, 2024 27 Seg Data Element Name Usage Comments Expected Value LOOP 2000A - BILLING PROVIDER HL Billing Provider Level R HL01 Hierarchical ID Number R Sequence number incremented for each occurrence of HL HL03 Level Code R Use 20 information Source HL04 Hierarchical Child Code R Use 1 Additional Subordinate PRV Billing Provider Specialty Information S Required for atypical providers PRV01 Provider Code R BI Billing PRV02 Reference Identification Qualifier R PXC Health Care Provider Taxonomy Code PRV03 Reference Identification R Allowed value from External Code List 682. LOOP 2010AA BILLING PROVIDER NAME NM1 Billing Provider Name R NM101 Entity ID Code R Use 85 billing provider NM102 Entity Type Qualifier R Allowed values: 1 for person 2 for non-person Use 1 for person Use 2 for non-person 837 Health Care Claim Companion Guides Version 2.8 January, 2024 28 Seg Data Element Name Usage Comments Expected Value NM103 Last Name or Organization Name R Billing Provider Last or Organizational Name NM104 Name First S Billing Provider First Name NM105 Name Middle S Billing Provider Middle Name NM107 Name Suffix S Billing Provider Name Suffix NM108 Billing Provider Identification Code Qualifier R Required for ALL NPI submitters, with the exception of atypical providers who have not been issued an NPI Number. For those atypical providers, The Billing Provider Secondary Identification (REF G2) must be provided in Loop 2010BB. See Implementation Guide for additional information. Use Value- XX NM109 Billing Provider Identifier R Covered entities send the National Provider ID (NPI) 837 Health Care Claim Companion Guides Version 2.8 January, 2024 29 Seg Data Element Name Usage Comments Expected Value N3 Billing Provider Address R Must be a Physical Address, Not a P.O. Box. If the Pay-To Address is a P.O. Box, it must be sent in the Pay- To Address (Loop 2010AB). N301 Address Information R Billing Provider Address Line N302 Address Information Second Address Line S Billing Provider Second Address Line N4 Billing Provider City State Zip R N401 City R Billing Provider City N402 State R Billing Provider State N403 Zip R Billing Provider Zip 837 Health Care Claim Companion Guides Version 2.8 January, 2024 30 Seg Data Element Name Usage Comments Expected Value REF Billing Provider Tax Identification R When NPI is submitted in the NM108 09 of this loop, either the EIN or SSN of the provider must be carried in this REF segment. The value that Carelon receives in this element will be returned on the 1099. REF01 Reference Identification Qualifier R Allowed values: EI Employer s Identification Number SY Social Security Number Use EI if the Provider ID is EIN Use SY if Provider ID is SSN REF02 Billing Provider Additional Identifier R EIN or SSN of the billing provider. REF Billing Provider UPIN License Info S REF01 Reference ID Qualifier R Allowed values: 0B State License Number 1G Provider UPIN Number Use 1G for UPIN number (Medicaid Number) REF02 Reference ID R UPIN information LOOP 2010AB PAY-TO ADDRESS NAME NM1 Pay-To-Address Name S This must be sent if the Pay-To Address is a P.O. Box. NM101 Entity ID Code R 87 Pay-to Provider NM102 Entity Type Qualifier R Allowed Values: 1 for person 2 for non-person Use 1 for person Use 2 for non-person 837 Health Care Claim Companion Guides Version 2.8 January, 2024 31 Seg Data Element Name Usage Comments Expected Value N3 Pay-To Address R N301 Address Information R First Address Line N302 Address Information S Second Address Line N4 Pay-To City State Zip R N401 City R N402 State R N403 Zip R 837 Health Care Claim Companion Guides Version 2.8 January, 2024 32 Seg Data Element Name Usage Comments Expected Value LOOP 2000B SUBSCRIBER HIERARCHICAL LEVEL HL Subscriber Hierarchical level R HL01 Hierarchical Level R Assigned by sender HL02 Hierarchical Parent ID Number R Assigned by sender HL03 Hierarchical Level Code R Use 22 for subscriber HL04 Hierarchical Child Code R Use 0 if subscriber is the patient Use 1 if subscriber is not the patient SBR Subscriber Information R SBR01 Payer Responsibility Sequence Number code R Use P for Primary Use S for Secondary Use T for Tertiary SBR02 Individual Relationship Code S Use 18 for Self SBR03 Subscriber Ref ID S Subscriber Group or Policy Number 5, 20, 32, 161, MBHP, MAM or HEA 5 for Fallon Health 20 for WellSense Health Plan Massachusetts 32 for WellSense New Hampshire Medicaid 161 for WellSense Senior Care Options 183 for WellSense Medicare Advantage (HMO) MBHP or MAM for Massachusetts Behavioral Health Partnership HEA for Health New England 837 Health Care Claim Companion Guides Version 2.8 January, 2024 33 Seg Data Element Name Usage Comments Expected Value SBR04 Name S Required when SBR03 is not used and the group name is available. Fallon Health or WellSense Health Plan Massachusetts or WellSense New Hampshire Medicaid or WellSense Senior Care Options or WellSense Medicare Advantage (HMO) or Massachusetts Behavioral Health Partnership or Health New England LOOP 2010BA SUBSCRIBER NAME NM1 Subscriber Name R NM101 Entity Id Code R Use IL Insured or Subscriber NM102 Entity Type Qualifier R Use 1 for person Use 2 for Non-Person Entity NM103 Name or organization name R Name Last or Organization Name NM108 Identification Code Qualifier R An identifier must be present in the subscriber loop. Refer to Implementation Guide for further details. Use MI Member Identification Number. NM109 Subscriber Primary Identifier R Member ID from Membership card Note: Medical Assistance Number can be used if applicable. LOOP 2010BB PAYER NAME NM1 Payer Name R NM101 Entity ID code R Use PR Payer 837 Health Care Claim Companion Guides Version 2.8 January, 2024 34 Seg Data Element Name Usage Comments Expected Value NM102 Entity Type Qualifier R Use 2 Non-Person Entity NM103 Payer Name R Destination payer name Use CARELON BEHAVIORAL HEALTH, INC. NM108 Identification Code Qualifier R Valid values: PI - Payer Identification XV - HCFA Plan ID (when mandated) Use PI Payer Identifier until the National Plan ID is mandated. NM109 Payer Identifier R Destination payer identifier Use BEACON963116116 REF Billing Provider Secondary Identification S This information is required if the provider is an atypical provider, who does not have an NPI present in the Billing Provider Loop (2010AA). REF01 Reference ID Qualifier R Valid values: G2 Provider Commercial Number LU Location Number Use G2 Provider Commercial Number REF02 Reference ID R Medicaid or State assigned provider identifier. LOOP 2300 CLAIM INFORMATION CLM Claim Information R CLM01 Patient Account Number R Patient Control Number Patient Control Number CLM02 Monetary Amount R Total Claim Charge Amount Total Claim Charge Amount CLM05-1 Facility Code Value R Place of service Place of service CLM05-2 Facility Code Qualifier R Use B place of Service Codes for Professional Use B place of Service Codes for Professional 837 Health Care Claim Companion Guides Version 2.8 January, 2024 35 Seg Data Element Name Usage Comments Expected Value CLM05-3 Claim Frequency Type Code R 1 Original 7 Replacement 8 Void Cancel of Prior Claim REF Payer Claim Control Number S Required if Claim Frequency Type Code is 7, or 8 REF01 Reference Identification Qualifier R F8 Original Reference Number REF02 Original Reference Number R If this is a correction to a previously submitted claim use the Carelon Behavioral Health claim number. Enter the whole claim number without spaces or dashes. Include leading and trailing zeros. REF Transmission Intermediaries ID S REF01 Reference Identification Qualifier R Use D9 Claim Number REF02 Original Reference Number R Unique document control number NTE Claim Received Date S This segment is used only after accepted agreement between trading partners NTE01 Note Reference Code R The value must be ADD for additional information ADD Additional Information 837 Health Care Claim Companion Guides Version 2.8 January, 2024 36 Seg Data Element Name Usage Comments Expected Value NTE02 Date Note R Date Claim Received Must use format CCYYMMDD (Pos. 1- 8) CCYYMMDD- Claim Receive Date HI Health Care Diagnosis Code R Do not include decimal point Diagnoses submitted must include all characters out to the furthest position as defined by the diagnosis coding system. HI01 Health Care Code Information R Principal Diagnosis HI01-1 Code List Qualifier Code R ABK- Principal Diagnosis- ICD10 HI01-2 Industry Code R Use ABK for ICD-10 Diagnosis when service date is 10 01 2015 and after. Use BK for ICD-9 Diagnosis when service date is 9 30 2015 and prior. HI02 Health Care Code Information S Additional Diagnosis HI02-1 Code List Qualifier Code R ABF- Diagnosis- ICD10 HI02-2 Industry Code R Use ABF for ICD-10 Diagnosis when service date is 10 01 2015 and after. Use BF for ICD-9 Diagnosis when service date is 9 30 2015 and prior. HI03 Code List Qualifier Code S Additional Diagnosis HI03-1 Code List Qualifier Code R ABF- Diagnosis- ICD10 HI03-2 Industry Code R Use ABF for ICD-10 Diagnosis when service date is 10 01 2015 and after. Use BF for ICD-9 Diagnosis when service date is 9 30 2015 and prior. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 37 Seg Data Element Name Usage Comments Expected Value HI04 Code List Qualifier Code S Additional Diagnosis HI04-1 Code List Qualifier Code R ABF- Diagnosis- ICD10 HI04-2 Industry Code R Use ABF for ICD-10 Diagnosis when service date is 10 01 2015 and after. Use BF for ICD-9 Diagnosis when service date is 9 30 2015 and prior. NM104 Name First S Referring Provider First Name Referring Provider First Name NM105 Name Middle S Referring Provider Middle Name Referring Provider Middle Name NM108 Identification Code Qualifier S Use Value XX NM109 Identification Code S This element contains the NPI for the Referring Provider. Use the NPI of the Referring Provider. LOOP 2310A REFERRING PROVIDER NAME NM1 Attending Provider Name S 837 Health Care Claim Companion Guides Version 2.8 January, 2024 38 Seg Data Element Name Usage Comments Expected Value NM101 Entity Id Code R Use DN for Referring Provider Use P3 for Primary Cary Provider NM102 Entity Type Qualifier R Use 1 for person NM103 Name or organization name R Referring Provider Last Name NM104 Name First S Referring Provider First Name NM105 Name Middle S Referring Provider Middle Name NM108 Identification Code Qualifier S Use Value XX NM109 Identification Code S This element contains the NPI for the Referring Provider. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 39 Seg Data Element Name Usage Comments Expected Value LOOP 2310B RENDERING PROVIDER NAME NM1 Rendering Provider Name S NM101 Entity Id Code R Use 82 for Rendering Provider NM102 Entity Type Qualifier R Use 1 for person Use 2 for Non-Person Entity NM103 Name or organization name R Rendering Provider Last or Organization Name NM104 Name First S Rendering Provider First Name NM105 Name Middle S Rendering Provider Middle Name NM108 Identification Code Qualifier S Use Value XX NM109 Identification Code S The NPI of the Rendering Provider. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 40 Seg Data Element Name Usage Comments Expected Value LOOP 2310C SERVICE FACILITY NAME NM1 Service Location Name S This Segment should only be used when the Service Facility Address is different from the Billing Provider Address provided in Loop 2010AA. NM101 Entity Id Code R Use 77 for Service Location NM102 Entity Type Qualifier R Use 2 for Non-Person Entity NM103 Name or organization name R Service Location Organization Name NM108 Identification Code Qualifier S Use Value XX NM109 Identification Code S Use the NPI of the Service Facility Location N3 Address Information S N301 Address Line 1 R N302 Address Line 2 S N4 Consumer City State Zip Code R N401 City Name R N402 State S 837 Health Care Claim Companion Guides Version 2.8 January, 2024 41 Seg Data Element Name Usage Comments Expected Value N403 Postal Code S LOOP 2320 COORDINATION OF BENEFITS (COB) OTHER PAYER INFORMATION SBR Subscriber Information S SBR01 Payer responsibility R This loop is for OTHER PAYER ONLY. If there is another payer whose liability precedes Carelon Behavioral Health coverage, do not submit claim until you have received payment or denial from the other payer. Use P - (Primary) Use S - (Secondary) Use T - (Tertiary) See Implementation Guide for additional Values SBR02 Individual Relationship Code R See Implementation Guide for other values Use 18 - Self SBR03 Reference Identification S Group or Policy Number SBR04 Name S Other Insured Group Name SBR05 Insurance Type Code S See Implementation Guide for valid values SBR09 Claim Filing Indicator S See Implementation Guide for valid values AMT COB Payer Paid Amount R AMT01 Amount Qualifier R Payer Amount Paid Use D - Payer Amount Paid AMT02 Monetary Amount R Amount Paid by the Other Payer AMT COB NON Covered Amount AMT01 Amount Qualifier Code R Non-covered charges -Actual Use A8 - Non-covered charges -Actual AMT02 Monetary Amount R Non-covered charge amount 837 Health Care Claim Companion Guides Version 2.8 January, 2024 42 Seg Data Element Name Usage Comments Expected Value OI Other Insurance Coverage Information R OI03 Benefits Assignment R Use N - NO Use W - not applicable Use Y -YES OI04 Patient Signature Source S See Implementation Guide for valid values OI06 Release of Information Code R See Implementation Guide for valid values LOOP 2330A OTHER SUBSCRIBER NAME INFORMATION NM1 S Required if Loop 2320 is present NM101 Entity ID R Use IL - Insured or Subscriber NM102 Entity Type R Use 1 Person NM103 Last Name R NM104 First Name S NM105 Middle Name S NM107 Suffix S NM108 Identification Code R Use MI - Member Identification Number NM109 Identification Number R Member Identification Number N3 Other Subscriber Address S N301 Address Information R Other Subscriber Address N4 Other Subscriber City State ZIP S N401 City Name R Other Subscriber City Name N402 State R Other Subscriber State N403 ZIP R Other Subscriber Zip LOOP 2330B OTHER PAYER NAME INFORMATION 837 Health Care Claim Companion Guides Version 2.8 January, 2024 43 Seg Data Element Name Usage Comments Expected Value NM1 Other Payer Name R NM101 Entity Identifier R Use PR - Payer NM102 Entity Type R Use 2 -Non-Person Entity NM103 Organization Name R Name of Payer (Other Insurance Company) NM108 ID Code Qualifier R Use PI - Payer Identification NM109 Identification Code R Payer ID N3 Other Payer Address S N301 Address Information R Address Information Address Information N4 Other Payer City State ZIP R N401 City Name R City Name N402 State Name R State Name N403 Postal Code R ZIP Code ZIP Code DTP Claim Adjudication Date R DTP01 Date Time Qualifier R Use 573 Date Claim Paid DTP02 Format Qualifier R Use D8 DTP03 Adjudication Date R YYYYMMDD LOOP 2400 SERVICE LINE LX Service Line Number R 837 Health Care Claim Companion Guides Version 2.8 January, 2024 44 Seg Data Element Name Usage Comments Expected Value LX01 Assigned Number R Number Assigned for differentiation within a transaction set SV1 Professional Service R SV101 Composite Medical Procedure Identifier R SV101-1 Product Service ID Qualifier R Use HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Use HC to identify health care financing administration. Use common procedural coding system (HCPCS) codes. SV101-2 Procedure Code R Procedure Code Procedure Code SV101-3 Procedure Modifier S Modifiers must be billed in the order they appear on the benefit grid. SV101-4 Procedure Modifier S Modifiers must be billed in the order they appear on the benefit grid. SV101-5 Procedure Modifier S Modifiers must be billed in the order they appear on the benefit grid. SV101-6 Procedure Modifier S Modifiers must be billed in the order they appear on the benefit grid. SV104 Quantity R Use whole number unit values. DTP Date Service Date R 837 Health Care Claim Companion Guides Version 2.8 January, 2024 45 Seg Data Element Name Usage Comments Expected Value DTP01 Date Time Qualifier R Use 472 Service DTP02 Date Time Period Format Qualifier R Valid Values: D8 Date Expressed in Format CCYYMMDD RD8 Date Range Expressed in Format CCYYMMDD-CCYYMMDD Use RD8 to specify a range of dates. The from and through service dates should be sent for each service line. DTP03 Date Time Period R Service Date LOOP 2430 LINE ADJUDICATION INFORMATION SVD Professional Service R SVD01 Payer ID R Payer Identification Code Number SVD02 Monetary Amount R Paid Amount SVD03-1 Procedure Code ID Qualifier R HC HCPCS SVD03-2 Procedure Code ID R SVD03-3 Modifiers S SVD03-4 Modifiers S SVD03-5 Modifiers S SVD03-6 Modifiers S 837 Health Care Claim Companion Guides Version 2.8 January, 2024 46 C h a p t e r 8 Institutional Claim Transaction Specifications 8.1. 837 Institutional Claim Transaction Specifications 837 Health Care Claim Companion Guides Version 2.8 January, 2024 41 Seg Data Element Name Usage Comments Expected Value HEADER ST Transaction Set Header R ST01 Transaction Set Identifier Code R Valid Value: 837 Health Care Claim Use 837 Health Care Claim ST02 Transaction set control number R Assigned by sender. Must equal SE02 ST03 Transaction R Same as GS08 BHT Beginning of Hierarchal Transaction R BHT01 Hierarchical Structure Code R Use 0019 BHT02 Transaction Set Purpose Code R Valid Values: 00 Original 18 Reissue Reissue Case where the transmission was interrupted and the receiver requests that the batch be sent again. Use 00 Original BHT03 Reference ID R Assigned by sender BHT04 Date R Transaction Set creation date CCYYMMDD BHT05 Time R Transaction Set Creation Time HHMM 837 Health Care Claim Companion Guides Version 2.8 January, 2024 42 Seg Data Element Name Usage Comments Expected Value BHT06 Transaction Type Code R Valid Values: 31 Subrogation Demand CH Chargeable RP Reporting Separate claim and encounter data into separate ISA IEA envelopes (files). Use CH for claims Use RP for encounters. LOOP 1000A SUBMITTER NAME NM1 Submitter Name R NM101 Entity Identifier Code R 41 Submitter NM102 Entity Type Qualifier R 1 person 2 Non-Person Entity NM103 Name Last or Organization Name R Name NM104 Name First S Name First Only if NM102 1 NM105 Name Middle S Name Middle Only if NM102 1 NM108 ID code Qualifier R 46 Electronic Transmitter ID number 46 ETIN NM109 Submitter Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use the Carelon Behavioral Health assigned submitter ID. Maximum 10 characters. LOOP 1000B RECEIVER NAME NM1 Receiver Name R NM101 Entity ID Code R 40 Receiver 837 Health Care Claim Companion Guides Version 2.8 January, 2024 43 Seg Data Element Name Usage Comments Expected Value NM102 Entity Type Qualifier R Use 2 Non-Person Entity NM103 Receiver Name R Use CARELON BEHAVIORAL HEALTH, INC. NM109 Receiver Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use BEACON963116116 LOOP 2010AA BILLING PROVIDER NAME NM1 Billing Provider Name R NM101 Entity Identifier Code R 85 Billing Provider NM102 Entity Type Qualifier R 2 Non-Person Entity 2 Non-Person Entity NM103 Name Last or Organization Name R Name Last or Organization NM108 Billing Provider Identification Code Qualifier R A business requirement by Carelon Behavioral Health. Use XX Centers for Medicare and Medicaid Services National Provider Identifier NM109 Billing Provider Identifier R This element contains the NPI for the Billing N3 Billing Provider Address R Must be a Physical Address, Not a P.O. Box. If the Pay-To Address is a P.O. Box, it must be sent in the Pay- To Address (Loop 2010AB). N301 Address R Billing Provider Address Billing Provider Address N4 Billing Provider City, State, ZIP R N401 City Name R City Name N402 State R State 837 Health Care Claim Companion Guides Version 2.8 January, 2024 44 Seg Data Element Name Usage Comments Expected Value N403 ZIP R ZIP REF Billing Provider Tax Identification R REF01 Reference Identification Qualifier R Use EI REF02 Billing Provider Additional Identifier R EIN of the billing provider. LOOP 2010AB PAY-TO-ADDRESS NAME NM1 Billing Provider Name R NM101 Entity Identifier Code R 87 Pay-To Provider NM102 Entity Type Qualifier R 2 Non-Person Entity 2 Non-Person Entity 837 Health Care Claim Companion Guides Version 2.8 January, 2024 45 Seg Data Element Name Usage Comments Expected Value N3 Pay-to Provider Address R N301 Address R Pay-to Provider Address 1 N302 Address R Pay-to Provider Address 2 N4 Pay-to Provider City, State, ZIP R N401 City Name R City Name N402 State R State N403 ZIP R ZIP LOOP 2000B SUBSCRIBER HIERARCHICAL LEVEL Subscriber Hierarchical Level HL01 Hierarchical ID number R Unique number assigned by sender Unique number assigned by sender HL02 Hierarchical Parent ID number Unique number assigned by sender Unique number assigned by sender HL03 Hierarchical Level Code R 22 Subscriber 22 Subscriber HL04 Child Code R Use 0 if subscriber is the patient Use 1 if subscriber is not the patient Use 0 if subscriber is the patient Use 1 if subscriber is not the patient 837 Health Care Claim Companion Guides Version 2.8 January, 2024 46 Seg Data Element Name Usage Comments Expected Value Subscriber Information R SBR01 Payer Responsibility Sequence Number code R Use P for Primary Use S for Secondary Use T for Tertiary SBR02 Individual Relationship Code S Use 18 for Self SBR03 Subscriber Ref ID S 5, 20, 32, 161, MBHP, MAM or HEA 5 for Fallon Health 20 for WellSense Health Plan Massachusetts 32 for WellSense New Hampshire Medicaid 161 for WellSense Senior Care Options 183 for WellSense Medicare Advantage (HMO) MBHP or MAM for Massachusetts Behavioral Health Partnership HEA | /kaggle/input/edi-db-835-837/837-health-care-claim-companion-guide.pdf | da20cac9edf74c6f8186b9d9268d0aab | da20cac9edf74c6f8186b9d9268d0aab_0 |
NM101 Entity ID Code R 40 Receiver 837 Health Care Claim Companion Guides Version 2.8 January, 2024 43 Seg Data Element Name Usage Comments Expected Value NM102 Entity Type Qualifier R Use 2 Non-Person Entity NM103 Receiver Name R Use CARELON BEHAVIORAL HEALTH, INC. NM109 Receiver Primary Identifier R This element contains the Electronic Transaction Identifier Number (ETIN). Use BEACON963116116 LOOP 2010AA BILLING PROVIDER NAME NM1 Billing Provider Name R NM101 Entity Identifier Code R 85 Billing Provider NM102 Entity Type Qualifier R 2 Non-Person Entity 2 Non-Person Entity NM103 Name Last or Organization Name R Name Last or Organization NM108 Billing Provider Identification Code Qualifier R A business requirement by Carelon Behavioral Health. Use XX Centers for Medicare and Medicaid Services National Provider Identifier NM109 Billing Provider Identifier R This element contains the NPI for the Billing N3 Billing Provider Address R Must be a Physical Address, Not a P.O. Box. If the Pay-To Address is a P.O. Box, it must be sent in the Pay- To Address (Loop 2010AB). N301 Address R Billing Provider Address Billing Provider Address N4 Billing Provider City, State, ZIP R N401 City Name R City Name N402 State R State 837 Health Care Claim Companion Guides Version 2.8 January, 2024 44 Seg Data Element Name Usage Comments Expected Value N403 ZIP R ZIP REF Billing Provider Tax Identification R REF01 Reference Identification Qualifier R Use EI REF02 Billing Provider Additional Identifier R EIN of the billing provider. LOOP 2010AB PAY-TO-ADDRESS NAME NM1 Billing Provider Name R NM101 Entity Identifier Code R 87 Pay-To Provider NM102 Entity Type Qualifier R 2 Non-Person Entity 2 Non-Person Entity 837 Health Care Claim Companion Guides Version 2.8 January, 2024 45 Seg Data Element Name Usage Comments Expected Value N3 Pay-to Provider Address R N301 Address R Pay-to Provider Address 1 N302 Address R Pay-to Provider Address 2 N4 Pay-to Provider City, State, ZIP R N401 City Name R City Name N402 State R State N403 ZIP R ZIP LOOP 2000B SUBSCRIBER HIERARCHICAL LEVEL Subscriber Hierarchical Level HL01 Hierarchical ID number R Unique number assigned by sender Unique number assigned by sender HL02 Hierarchical Parent ID number Unique number assigned by sender Unique number assigned by sender HL03 Hierarchical Level Code R 22 Subscriber 22 Subscriber HL04 Child Code R Use 0 if subscriber is the patient Use 1 if subscriber is not the patient Use 0 if subscriber is the patient Use 1 if subscriber is not the patient 837 Health Care Claim Companion Guides Version 2.8 January, 2024 46 Seg Data Element Name Usage Comments Expected Value Subscriber Information R SBR01 Payer Responsibility Sequence Number code R Use P for Primary Use S for Secondary Use T for Tertiary SBR02 Individual Relationship Code S Use 18 for Self SBR03 Subscriber Ref ID S 5, 20, 32, 161, MBHP, MAM or HEA 5 for Fallon Health 20 for WellSense Health Plan Massachusetts 32 for WellSense New Hampshire Medicaid 161 for WellSense Senior Care Options 183 for WellSense Medicare Advantage (HMO) MBHP or MAM for Massachusetts Behavioral Health Partnership HEA for Health New England SBR04 Name S Fallon Health or WellSense Health Plan Massachusetts or WellSense New Hampshire Medicaid or WellSense Senior Care Options or WellSense Medicare Advantage (HMO) or Massachusetts Behavioral Health Partnership or Health New England LOOP 2010BB PAYER NAME NM1 Payer Name R NM101 Entity ID code R PR Payer NM102 Entity Type Qualifier R 2 Non-Person Entity NM103 Payer Name R Destination payer name. Use CARELON BEHAVIORAL HEALTH, INC. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 47 Seg Data Element Name Usage Comments Expected Value NM108 Identification Code Qualifier R Valid values: PI Payer Identification XV HCFA Plan ID (when mandated) Use PI Payer Identifier until the National Plan ID is mandated. NM109 Payer Identifier R Destination payer identifier Use BEACON963116116 LOOP 2300 CLAIM INFORMATION CLM Claim Information R CLM01 Claim Submitter ID R Claim Submitter s Patient Control Number CLM02 Monetary Amount R Total Claim Charge Amount CLM05-1 Facility Code Value R Facility Type Code CLM05-2 Facility Code Qualifier R A Uniform Billing Claim Form CLM05-3 Claim Frequency Type Code R 1 Original 7 Replacement 8 Void DTP Discharge Hour S DTP01 Date Time Qualifier R Use 096 - Discharge DTP02 Date Time Qualifier R TM DTP03 Date Time Period R HHMM DTP Statement Date S DTP01 Date Time Qualifier R Use 434 -Statement 837 Health Care Claim Companion Guides Version 2.8 January, 2024 48 Seg Data Element Name Usage Comments Expected Value DTP02 Date Time Period Format Qualifier R RD8 Range of Dates Expressed in Format (CCYYMMDD-CCYYMMDD) DTP03 Date Time Period R Statement from and to Date DTP Admission Date Hour S DTP01 Date Time Qualifier R Use 435 Admission DTP02 Date Time Format Qualifier R Valid Values: D8 Date Expressed in Format CCYYMMDD. DT Date and Time Expressed in Format CCYYMMDDHHMM Use DT - Date and Time Expressed in format (CCYYMMDDHHMM) DTP03 Date Time Period R Admission Date and Hour CL1 Institutional Claim Code R CL101 Admission Type Code R Code indicating the priority of this admission From Code Source 231 CL102 Admission Source Code R Code indicating the source of this admission From Code Source 230 CL103 Patient Status Code R Code indicating patient status as of the statement covers through date From Code Source 239 PWK Claim Supplemental Information S PWK02 Attachment Transmission Code R AA Available on Request at Provider Site. Use AA Available on Request at Provider Site. 837 Health Care Claim Companion Guides Version 2.8 January, 2024 49 Seg Data Element Name Usage Comments Expected Value REF Payer Claim Control Number S Required if Claim Frequency Type Code is 7 or 8 REF01 Reference Identification Qualifier R F8 Original Reference Number REF02 Original Reference Number R If this is a correction to a previously submitted claim use the CarelonBehavioral Health claim number. Enter the whole clai number without spaces or dashes. Include leading and trailing zeros. REF Transmission Intermediaries ID S This segment is used only after accepted agreement between trading partners REF01 Reference Identification Qualifier R The value must be D9 for Unique document control number D9 Unique document control number REF02 Original Reference Number R Unique document control number Unique document control number NTE Claim Received Date S This segment is used only after accepted agreement between trading partners NTE01 Note Reference Code R The value must be UPI for additional information UPI Additional Information 837 Health Care Claim Companion Guides Version 2.8 January, 2024 50 Seg Data Element Name Usage Comments Expected Value NTE02 Date Note R Date Claim Received Must use format CCYYMMDD (Pos. 1- 8) CCYYMMDD- Claim Receive Date HI Principal Diagnosis R HI01-1 Code List Qualifier Code R BK - Principal Diagnosis ICD-9 ABK- Principal Diagnosis- ICD10 HI01-2 Industry Code R Use ABK for ICD-10 Diagnosis when service date is 10 01 2015 and after. Use BK for ICD-9 Diagnosis when service date is 9 30 2015 and prior. HI01-9 Yes No Condition or Response Code S Present on Admission Indicator N for No U for Unknown W for Not Applicable Y for Yes HI Admitting Diagnosis S HI01-1 Code List Qualifier Code R BJ - Admitting Diagnosis ICD-9 ABJ- Admitting Diagnosis- ICD10 837 Health Care Claim Companion Guides Version 2.8 January, 2024 51 Seg Data Element Name Usage Comments Expected Value HI01-2 Industry Code R Use ABJ for ICD-10 Diagnosis when service date is 10 01 2015 and after. Use BJ for ICD-9 Diagnosis when service date is 9 30 2015 and prior. HI Patient s Reason for Visit S HI01-1 Code List Qualifier Code R PR Patient reason for visit ICD-9 APR- Patient reason for visit - ICD10 HI01-2 Industry Code R Use APR for ICD-10 when service date is 10 01 2015 and after. Use PR for ICD-9 when service date is 9 30 2015 and prior. HI External Cause of Injury S HI01-1 Code List Qualifier Code R BN External cause of injury ICD-9 ABN- External cause of injury - ICD10 HI01-2 Industry Code R Use ABN for ICD-10 when service date is 10 01 2015 and after. HI Other Diagnosis Information S HI01-1 Code List Qualifier Code R BF - Other Diagnosis ICD-9 ABF- Other Diagnosis- ICD10 837 Health Care Claim Companion Guides Version 2.8 January, 2024 52 Seg Data Element Name Usage Comments Expected Value HI01-2 Industry Code R Use ABF for ICD-10 Diagnosis when service date is 10 01 2015 and after. Use BF for ICD-9 Diagnosis when service date is 9 30 2015 and prior. HI Principal Procedure Information S HI01-1 Code List Qualifier Code R BR - Principal Procedure ICD-9 BBR- Principal Procedure- ICD10 HI01-2 Industry Code R Use BBR when service date is 10 01 2015 and after. Use BR when service date is 9 30 2015 and prior. HI Other Procedure Information S HI01-1 Code List Qualifier Code R BQ - Other Procedure ICD-9 BBQ- Other Procedure- ICD10 HI01-2 Industry Code R Use BBQ when service date is 10 01 2015 and after. Use BQ when service date is 9 30 2015 and prior. LOOP 2310A ATTENDING PROVIDER NAME NM1 Attending Provider Name S 837 Health Care Claim Companion Guides Version 2.8 January, 2024 53 Seg Data Element Name Usage Comments Expected Value NM101 Entity ID Code R 71 Attending Physician 71 Attending Physician NM102 Entity Type Qualifier R 1 Person 1 Person NM103 Name Last or Organization Name R Name Last or Organization Name Name Last or Organization Name NM104 Name First S Attending Provider First Name Attending Provider First Name NM105 Name MI S Attending Provider Middle Name Attending Provider Middle Name NM108 ID Code Qualifier R Required for ALL NPI submitters, with the exceptions of atypical providers who have not been issued an NPI Number. For the atypical providers, the Attending Provider secondary Identification (REF G2) must be provided in Loop 2310A. See Implementation Guide for additional information. Use XX Centers for Medicare and Medicaid NPI NM109 ID Code R Attending Provider Primary Identifier Attending Provider Primary Identifier PRV Attending Provider Specialty Information S 837 Health Care Claim Companion Guides Version 2.8 January, 2024 54 Seg Data Element Name Usage Comments Expected Value PRV01 Provider Code R Use AT -Attending Use AT -Attending PRV02 Reference ID Qualifier R Use PXC - Provider Taxonomy Code Use PXC - Provider Taxonomy Code PRV03 Reference ID R Provider Taxonomy Code Provider Taxonomy Code REF Attending Provider Secondary ID S REF01 Reference ID Qualifier R G2 Provider Commercial, Medicaid, Medicare Number 1G UPIN number G2 Provider Commercial, Medicaid, Medicare Number 1G UPIN number REF02 Reference ID R LOOP 2310E- SERVICE FACILITY LOCATION NAME NM1 Service Facility Location Name S NM101 Entity ID code R Use 77 Service Location Use 77 Service Location NM102 Entity Type Qualifier R 2 Non-person Entity 2 Non-person Entity 837 Health Care Claim Companion Guides Version 2.8 January, 2024 55 Seg Data Element Name Usage Comments Expected Value NM103 Provider Site name R Provider Site Name Provider Site Name NM108 ID Code Qualifier R XX Centers for Medicare and Medicaid NPI XX NM109 ID Code R ID Code ID Code LOOP 2320 COORDINATION OF BENEFITS (COB) OTHER PAYER INFORMATION AMT COB Payer Paid Amount R AMT01 Amount Qualifier Code R Use D Payer Amount Paid AMT02 Monetary Amount R When submitting claims with multiple claim lines where not all claim lines have a COB relationship; send separate claims. Amount Paid by the Other Payer. LOOP 2400 SERVICE LINE NUMBER LX Service Line Number R LX01 Assigned Number R Counter. Assigned by Sender Counter. Assigned by Sender SV2 Institutional Service Line R SV201 Product Service ID R Service Line Revenue Code Service Line Revenue Code SV202-1 Product Service ID Qualifier R HC Health Care Financing Administration Common Procedural Coding System (HCPCS) codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) codes SV202-2 Product Service ID R Procedure Code Procedure Code SV202-3 Product Service Modifier S Modifier 1 Modifier 1 837 Health Care Claim Companion Guides Version 2.8 January, 2024 56 Seg Data Element Name Usage Comments Expected Value SV202-4 Product Service Modifier S Modifier 2 Modifier 2 SV202-5 Product Service Modifier S Modifier 3 Modifier 3 SV205 Quantity S Service Units Use whole number unit values. DTP Service Date S DTP01 Date Time Qualifier R 472 - Service 472 - Service DTP02 Date Time Period Qualifier R D8 - CCYYMMDD RD8 - range of dates(CCYYMMDD- CCYYMMDD) D8 - CCYYMMDD RD8 - range of dates(CCYYMMDD- CCYYMMDD) DTP03 Date Time Period R Service Date Service Date LOOP 2430 LINE ADJUDICATION INFORMATION SVD Professional Service R SVD06 Assigned Number R Number of Units Paid for by Other Payer Whole Units Only | /kaggle/input/edi-db-835-837/837-health-care-claim-companion-guide.pdf | da20cac9edf74c6f8186b9d9268d0aab | da20cac9edf74c6f8186b9d9268d0aab_1 |
835 - Companion Guide June 28, 2022 005010X221A1 835 1 835 Health Care Claim Payment Advice Companion Guide Refers to ASC X12 835 Technical Report Type 3 Guide HIPAA V5010X221A1 Version: 1.1 Publication: June 28, 2022 Author: Delta Dental 835 - Companion Guide June 28, 2022 005010X221A1 835 2 Disclosure Statement This document is Copyright 2013 by Delta Dental of California. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X12. Preface This Companion Guide to the ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Delta Dental of California. Transmissions based on this companion guide, used in tandem with the X12N Technical Report Type 3 Guides are compliant with both X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Technical Report Type 3 Guides. 835 - Companion Guide June 28, 2022 005010X221A1 835 3 Table of Contents 1 Introduction.............................................................................................................. 5 1.1 Scope............................................................................................................................ 5 1.2 Overview....................................................................................................................... 5 1.3 References.................................................................................................................... 5 2 Getting Started......................................................................................................... 7 2.1 Working with Delta Dental of California......................................................................... 7 2.2 Trading Partner Registration......................................................................................... 7 2.3 Trading Partner Enrollment Onboarding........................................................................ 7 3 Notes to the Trading Partners................................................................................. 8 3.1 Business Use and Purpose........................................................................................... 8 3.2 Claims Types................................................................................................................ 8 3.3 Data Sources................................................................................................................ 8 3.4 Generation Frequency................................................................................................... 8 3.5 Data Content Structure.................................................................................................. 9 3.6 Validation Balancing...................................................................................................... 9 3.7 Delimeters..................................................................................................................... 9 3.8 Other............................................................................................................................. 9 4 Testing with the Payer........................................................................................... 10 4.1 Testing Requirements................................................................................................. 10 4.2 Provider 835 Request Enrollment File......................................................................... 11 4.3 Provider 835 Request Header Record Layout............................................................. 11 4.4 Provider 835 Request Detail Record Layout................................................................ 13 5 Connectivity with the Payer Communications.................................................. 15 5.1 Transmission Administrative Procedures..................................................................... 15 5.1.1 Re-transmission procedures.............................................................................. 15 5.2 Communication Protocols Specifications..................................................................... 15 5.3 Passwords.................................................................................................................. 15 6 Contact information............................................................................................... 16 6.1 EDI Customer Service................................................................................................. 16 6.2 Provider Service Number............................................................................................ 16 6.3 Applicable websites e-mail........................................................................................ 16 835 - Companion Guide June 28, 2022 005010X221A1 835 4 7 Control Segments Envelopes............................................................................. 17 7.1 ISA Interchange Control Header................................................................................. 17 7.2 GS Functional Group Header...................................................................................... 17 7.3 ST Transaction Set Header......................................................................................... 18 7.4 BPR Financial Information........................................................................................... 19 7.5 TRN Reassociation Trace Number.............................................................................. 21 7.6 REF Receiver Identification......................................................................................... 21 7.7 N1 Payer Identification................................................................................................ 22 7.8 PER Payer WEB Site.................................................................................................. 22 7.9 N1 Payee Identification............................................................................................... 23 7.10 N3 Payee Address...................................................................................................... 24 7.11 N4 Payee City, State, Zip Code................................................................................... 24 7.12 REF Payee Additional Identification............................................................................ 24 7.13 CLP Claim Payment Information................................................................................. 24 7.14 NM1 Patient Name...................................................................................................... 25 7.15 NM1 Insured Name..................................................................................................... 26 7.16 NM1 Service Provider Name....................................................................................... 27 7.17 REF Rendering Provider Identification (Loop 2100).................................................... 29 7.18 SVC Service Payment Information.............................................................................. 29 7.19 REF Service Identification........................................................................................... 29 7.20 REF Line Control Number........................................................................................... 29 7.21 REF Rendering Provider Information (2110)............................................................... 29 7.22 REF HealthCare Policy Identification........................................................................... 30 7.23 PLB Provider Adjustments.......................................................................................... 30 8 Acknowledgements............................................................................................... 31 8.1 999 Functional Acknowledgment................................................................................. 31 8.2 TA1 Interchange Acknowledgment.............................................................................. 31 Document Revision History....................................................................................... 32 835 - Companion Guide June 28, 2022 005010X221A1 835 5 1 Introduction Under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Secretary of the Department of Health and Human Services (HHS) is directed to adopt standards to support the electronic exchange of administrative and financial health care transactions. The purpose of the Administrative Simplification portion of HIPAA is enable health information to be exchanged electronically and to adopt standards for those transactions. 1.1 Scope This companion guide is intended for all Trading Partners interested in exchanging HIPAA compliant X12 transactions with any of Enterprise Delta Dental Payers. It is intended to be used in conjunction with X12N Implementation Guides and is not intended to contradict or exceed X12 standards. It contains information about specific Delta Dental of California requirements for processing following X12N Implementation Guides: Health Care Claim Payment Advice 835 Implementation Guide ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3), version 005010X221A1 All instructions in this document are written using information known at the time of publication and are subject to change. 1.2 Overview The purpose of this document is to introduce and provide information about Delta Dental s Enterprise solution for receiving 835 transactions. This document covers how Delta Dental will work with Trading Partners on testing, connectivity, contact information, control segments envelopes, payer specific business rules and limitations, acknowledgements, and trading partner agreements. 1.3 References 835 - Companion Guide June 28, 2022 005010X221A1 835 6 The ASC X12N 835 (version 005010X221A1) Technical Report Type 3 guide for Health Care Claim Payment Advice (835) has been established as the standard for payments transactions and is available at http: store.x12.org store healthcare- 5010-original-guides. Delta Dental of California s documentation on transactions for Trading Partners is located at: http: www.deltadentalins.com dentists edi-support.html. 835 - Companion Guide June 28, 2022 005010X221A1 835 7 2 Getting Started 2.1 Working with Delta Dental of California Entities interested in receiving 835 Electronic Remittance Advice (ERA) via the Delta Dental enterprise solution should email or call the Delta Dental EDI contact related to Trading Partner Relations. 2.2 Trading Partner Registration New entities must submit in writing or email a request to become a Trading Partner to the Delta Dental of California EDI contact related to Trading Partner Relations. Delta Dental reserves the right to have new Trading Partners use existing Trading Partner connections. In the request, submitter must include the following information: Contact Name Company Name Address, City, State and Zip E-Mail address of contact Telephone of contact Number of Delta Enterprise Provider Clients Served 2.3 Trading Partner Enrollment Onboarding All Trading Partners, Clearinghouses, and Providers groups will be provided with applicable agreement during enrollment onboarding period. 835 - Companion Guide June 28, 2022 005010X221A1 835 8 3 Notes to the Trading Partners 3.1 Business Use and Purpose This document provides a statement of the 835 utilization requirements unique to Delta Dental processing. Clearinghouses and Trading Partners must use this guide in conjunction with the 835 Health Care Claim Payment Advice Transaction Implementation Guide (TR3). 3.2 Claims Types The supported claim types are as follows: 1. Dental Claims 2. Dental Pre-Treatment Estimates Delta Dental s Notes for the Trading Partners: DeltaCare claims encounters and Delta Vision claim types are not supported at this time. This will be part of DeltaCare Phase 2 conversion targeted by end of 1st QTR 2014. 3.3 Data Sources Remittance Advices and Pre-treatment Estimates returned in the 835 include finalized claims pre-treatment estimates from the following submission sources: 1. Electronic claims (837D) 2. Paper claims 3. Manually-entered System-generated claims to Delta Dental's claims adjudication system Delta Dental s Notes for the Trading Partners: Once Provider Groups Providers are enrolled to receive 835 ERA, the applicable 835 ERA will be generated and sent after each Payment Processing (PP) cycle regardless of the submission sources. 3.4 Generation Frequency 1. Delta Dental's system produces Individual Remittance Advice and Pre-Treatment Estimate transactions once a week for each Delta Dental payer. This is based on weekly Payment Processing (PP) schedules defined for each Delta Dental payer. 2. The Individual Remittance Advice and or Pre-Treatment Estimate transactions are batched at the end of the day into an 835 EDI file. The 835 EDI files are batched based on specific Trading Partner Delta Dental Payers. If a system 835 - Companion Guide June 28, 2022 005010X221A1 835 9 limitation or agreed transmission size limitation is met, multiple 835 EDI files may be generated for each TP Payers. 3. Batching of X12 835 transactions occurs once a day after each Payment Processing (PP) cycles. 3.5 Data Content Structure 1. An 835 transaction will have one Interchange Group (ISA IEA), one Functional Group (GS GE), and may have one or more Transaction Sets (ST SE). 2. A Transaction Set (ST SE) may contain either an individual Pre-Treatment Estimate or an Individual Remittance Advice. 3. A Remittance Advice will reflect claims and service lines details associated with a payment. 4. Adjustments will be returned in 2110 Service Payment Information Loop, CAS segment. The CAS segment in 2100 Claim Payment Information loop is not utilized by Delta Dental. 3.6 Validation Balancing HIPAA Validation levels 1, 2, and 3 will be performed on the generated 835 EDI file(s). The amounts reported in the 835 will be balanced at the service line, claim, and transaction levels. 3.7 Delimeters Segment Separator (tilde) Data Element Separator (asterisk) Sub-element Separator: (colon) Repetition Separator (caret) 3.8 Other 1. Only Delta Dental-utilized loops and segments are included in this companion guide. 2. Data elements not utilized by Delta Dental are noted accordingly as "Not Utilized". 3. Codes not utilized by Delta Dental are excluded from this guide. 4. Supplemental notes (Delta Dental's Note for the Trading Partner), if applicable, are added at the segment or data element level. 835 - Companion Guide June 28, 2022 005010X221A1 835 10 4 Testing with the Payer 4.1 Testing Requirements Trading Partner will use the following steps to test with any of Enterprise Delta Dental Payers. Step 1: Trading Partner Registration Trading Partner should contact Delta Dental of California to complete and submit the Trading Partner Agreement Form for registration process. Step 2: Trading Partner Authentication Delta Dental will verify the information on the Trading Partner Agreement Form and will approve the Submitter ID requests. Step 3: Trading Partner Validation Testing Testing environment will be setup between Trading Partners and Delta Dental to allow for end-to-end system integration and Trading Partner Validation (TPV). Trading Partner should will receive 835 ERAs test transactions and verify that all systems involved can properly receive and process X12 compliant transactions. The Usage Indicator (ISA15) on 835 ERA s must be T. Step 4: Trading Partner Implementation Once Trading Partner Validation (TPV) and end-to-end system integration testing is complete, a Trading Partner will be migrated to Production environment and can begin to receive and process 835 ERA transactions. The Usage Indicator (ISA15) on 835 ERA s must be P. 835 - Companion Guide June 28, 2022 005010X221A1 835 11 4.2 Provider 835 Request Enrollment File Trading Partners who are interested in setting up Providers for 835 ERA must submit Provider Enrollment File. The following information must be provided to setup any Providers to receive 835 ERA. Fixed Length Records 200 Bytes File Type Text File Name DLTAP835.txt 4.3 Provider 835 Request Enrollment File Notifications Delta Dental will perform a series of file level validations on each 835 provider enrollment file based on the specifications outlined in section 4.4 and 4.5 of this document. If a provider enrollment file fails any of the validation at either the header level or the detail level the corresponding trading partner sender will receive a file processing failure notification via email with the below mentioned information and none of the provider records from the file will be enrolled for the 835 ERA until the file is corrected and resubmitted. Notification Method Email Sender noreply-Prod-Moveit delta.org Subject Provider 835 Enrollment File Processing Failure On Date MM DD YYYY Body File provider 835 enrollment file name has failed file format validations and will not be processed further by Delta Dental. Please correct and resubmit the file to ensure enrollment of the corresponding providers for the 835 ERA process. For further inquiries or questions please reach out to deltadentalproduction delta.org. Thank you, Delta Dental 835 - Companion Guide June 28, 2022 005010X221A1 835 12 4.4 Provider 835 Request Header Record Layout Field Name Description Length Start Position Technical Specification Record Type PR0 identifiers Header 3 1 Must contain a value or PR0. This is Uppercase PR followed by the number zero. File ID Identifies that this is a file of Provider ID's that have requested electronic remittance 9 4 Must contain a value of P835REQST. All letters must be uppercase. Record Count Total Number of PR1 Provider 835 Request Records Sent on File 9 13 Numeric Left Pad with Zeros Trading Partner Name Identifies Trading Partner. 15 22 Alphanumeric - case sensitive Right Pad with Spaces: Valid Values are: EMDEON EHG TESIA QSI SecureEDI Trading Partner Receiver ID Identifies Trading Partner. 8 37 Alphanumeric - case sensitive: for EMDEON value is 'DDNEIC00' for EHG value is 'DDSRIX00' for TESIA value is 'DDTESX00' for QSI value is 'DDQSIX00' for SecureEDI value is 'DDSEDI00' 835 - Companion Guide June 28, 2022 005010X221A1 835 13 Create Date Date File was created 8 45 CCYYMMDD - must be valid date Application Reciever Code Value to be populated on 835's 15 53 Value to be determinied by Trading Partner Filler 133 68 Spaces 835 - Companion Guide June 28, 2022 005010X221A1 835 14 4.5 Provider 835 Request Detail Record Layout Field Name Description Length Start Position Technical Specification Record Type PR1 Identifiers Provider Request Detail Record 3 1 PR1 Provider Group Tax ID Number TIN of Provider Group Requesting electronic 835 9 4 Alphanumeric - Right Pad with Spaces Provider Group Name Name of Group Provider 30 13 Alphanumeric - Right Pad with Spaces Provider Group NPI NPI for the Group Provider. This is the Type 2 NPI. 30 43 Alphanumeric - Right Pad with Spaces Provider Group 835 Dual Delivery Requested Indicates whether or not 835 Dual Delivery is requested or waived. Dual Delivery refers to the 835 start-up period where the provider will receive both paper and electronic 835's 1 73 Alphanumeric Y Provider Group wants 835 dual Delivery. They will receive both paper and electronic 835's for the number of days specified in Provider Group Dual Delivery Days. N Provider Group waives 835 dual delivery period. This Provider Group wants to only receive electronic 835's once they are setup up. NOTE: If this field is left blank or contains any value other than 'N' or 'Y', the default value of 'Y' will be used. 835 - Companion Guide June 28, 2022 005010X221A1 835 15 Provider Group Dual Delivery Days 2 74 Alphanumeric - Right Pad with Spaces This is the number of days (1 - 99) during which a provider group will receive both paper and electronic 835's. Note: This field is ignored when Dual Delivery Requested is 'N'. When the Dual Delivery Requested is 'Y' and this field is "0" or non_numeric, the default of 31 days will be used. Keep in mind that Delta Dental only pays claims weekly so if the days is set low it is possible that the Dual Delivery Period will end before any 835's are generated. Filler 125 76 Spaces 835 - Companion Guide June 28, 2022 005010X221A1 835 16 5 Connectivity with the Payer Communications 5.1 Transmission Administrative Procedures Trading Partner must use Delta Dental s designated secured FTP drop zone - https: ftp.delta.org to login and retrieve 835 X12 files. Trading Partner using the designated FTP drop zone must use authorized User ID and Password to login and retrieve 835 X12 files. 5.1.1 Re-transmission procedures Trading Partners must send a request to Delta Dental s EDI Contact for any missing 835 X12 files for re-transmission. 5.2 Communication Protocols Specifications The Delta Dental enterprise solution for 835 transactions supports transactions formatted according to the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3). 5.3 Passwords Delta Dental of California security policies requires Trading Partners to use authorized User ID and Password to login via the designated secured FTP site https: ftp.delta.org. 835 - Companion Guide June 28, 2022 005010X221A1 835 17 6 Contact information 6.1 EDI Customer Service Trading Partner Relations Manager: Rajkumar Narayanaswamy Phone Number: 415.802.9243 Email Address: rnarayanaswamy delta.org Operation Hours: Monday through Friday between 8:00 a.m. and 5:00 p.m., Pacific Standard Time Excluding the following major holidays: New Year s Day (1 1) Martin Luther King s Day (3rd Monday in January) President s Day (3rd Monday in February) Memorial Day (Last Monday in May) Independence Day (7 4) Labor Day (1st Monday in September) Thanksgiving Day (4th Thursday in November) Day after Thanksgiving Day (4th Friday in November) Christmas Eve (12 24) Christmas Day (12 25) 6.2 Provider Service Number If you have questions regarding information related to subscribers that are non- technical, contact center information can be found at the following: http: www.deltadentalins.com about contact 6.3 Applicable websites e-mail http: www.deltadentalins.com about contact http: www.deltadentalins.com dentists edi-support.html 835 - Companion Guide June 28, 2022 005010X221A1 835 18 7 Control Segments Envelopes 7.1 ISA Interchange Control Header Delta Dental's Notes for the Trading Partner: The Table describes the value specifically required by Delta Dental 835 transaction within the ISA Header. The Delta Dental 835 transaction does not expect any custom values for the IEA segment. Please follow the rules as specified by the TR3. Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes N A ISA ISA01 Authorization Information Qualifier 00 ISA02 Authorized Information 10 Blank Spaces ISA03 Security Information Qualifier 00 ISA05 Interchange ID Qualifier ZZ ISA04 Security Information 10 Blank Spaces ISA06 Interchange Sender ID 942411167 ISA07 Interchange ID Qualifier ZZ ISA08 Interchange Receiver ID As specified for each Trading Partner ISA09 Interchange Date YYMMDD ISA10 Interchange Time HHMM ISA11 Repetition Separator ISA12 Interchange Control Version Number 00501 ISA13 Interchange Control Number 000000001 Starts with 000000001 ISA14 Acknowledgment Requested 0 0 No ACK (TA1 or 999) Requested; 1 - No ACK (TA1 or 999) Requested ISA15 Interchange Usage Indicator T P T Test Data; P Production Data ISA16 Component Element Separator: 7.2 GS Functional Group Header Delta Dental's Notes for the Trading Partner: 835 - Companion Guide June 28, 2022 005010X221A1 835 19 The table below describes Delta Dental of California s use of the functional group control segments. It includes a description of expected application sender and receiver codes. Also included in this section is a description concerning how Delta Dental of California expects functional groups to be sent and how Delta Dental of California will send functional groups. These discussions will describe how similar transaction sets will be packaged and Delta Dental of California s use of functional group control numbers. The Delta Dental 835 transaction does not expect any custom values for the GE segment. Please follow the rules as specified by the TR3 for the GE segment. Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes N A GS GS01 Functional Identifier Code HP GS02 Application Sender's Code 942411167 GS03 Application Receiver's Code As specified for each Trading Partner GS04 Date YYYYMMDD GS05 Time HHMM GS06 Group Control Number 1 GS07 Responsible Agency Code X GS08 Version Release Industry Identifier Code 005010X221A1 7.3 ST Transaction Set Header Delta Dental's Notes for the Trading Partner: The Delta Dental 835 does not expect any custom values for the ST segments. Please follow the rules as specified by the TR3. Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes N A ST ST01 Transaction Set Identifier Code 835 ST02 Transaction Set Control Number Starts with 0001 or 000000001 835 - Companion Guide June 28, 2022 005010X221A1 835 19 7.4 BPR Financial Information Delta Dental's Notes for the Trading Partner: BPR05 through BPR10 and BPR12 through BPR15 are sent when BPR04 is ACH. Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes N A BPR BPR01 Transaction Handling Code H - Notification Only; I - Remittance Information Only BPR02 Monetary Amount Total Actual Provider Payment Amount including Interest BPR03 Credit Debit Flag Code C - Credit As specified for each Trading Partner BPR04 Payment Method Code ACH - Automated Clearing House (ACH); CHK Check; NON - Non-Payment Data BPR05 Payment Format Code CCP- Cash Concentration Disbursement plus Addenda (CCD ) (ACH) BPR06 (DFI) ID Number Qualifier 01 - ABA Transit Routing Number Including Check Digits (9 digits); 04 - Canadian Bank Branch and Institution Number BPR07 (DFI) Identification Number External Code List Name: 91 Description: Canadian Financial Institution Branch and Institution Number External Code List Name: 60 Description: (DFI) Identification Number 835 - Companion Guide June 28, 2022 005010X221A1 835 20 External Code List Name: 4 Description: ABA Routing Number BPR08 Account Number Qualifier DA - Demand Deposit BPR09 Account Number BPR10 Originating Company Identifier Payer Tax ID prefixed with "1 BPR11 Originating Company Supplemental Payer ID from Delta Dental's system, may or may not be identical to the Payer ID from submitted claim. BPR12 (DFI) ID Number Qualifier 01 - ABA Transit Routing Number Including Check Digits (9 digits); 04 - Canadian Bank Branch and Institution Number BPR13 (DFI) Identification Number External Code List Name: 91 Description: Canadian Financial Institution Branch and Institution Number External Code List Name: 60 Description: (DFI) Identification Number External Code List Name: 4 Description: ABA Routing Number BPR14 Account Number Qualifier DA- Demand Deposit; SG Savings BPR15 Account Number BPR16 Date Possible values: Check Issue Date (when BPR04 value is "CHK") 835 - Companion Guide June 28, 2022 005010X221A1 835 21 EFT Effective Date (when BPR04 value is "ACH") Claim Receipt Date (when BPR04 value is "NON") 7.5 TRN Reassociation Trace Number Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes N A TRN TRN01 Trace Type Code 1 - Current Transaction Trace Numbers TRN02 Reference Identification TRN03 Originating Company Identifier Payer Tax ID prefixed with "1" TRN04 Reference Identification Payer ID from Delta Dental's system, may or may not be identical to the Payer ID from submitted claim. 7.6 REF Receiver Identification Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes N A REF REF01 Reference Identification Qualifier EV - Receiver Identification Number REF02 Reference Identification Delta Dental's Notes for the Trading Partner: Trading Partner ID 835 - Companion Guide June 28, 2022 005010X221A1 835 22 7.7 N1 Payer Identification Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 1000A N1 N101 Entity Identifier Code PR Payer N102 Name Please refer to Delta Dental Enterprise Programs and corresponding Payer ID below. N103 Identification Code Qualifier XV - Centers for Medicare and Medicaid Services Plan ID N104 Identification Code External Code List Name: 540 Description: Centers for Medicare and Medicaid Services Plan ID Delta Dental Program Payer ID Delta Dental of California 77777 Delta Dental of Delaware 51022 Delta Dental of West Virginia 31096 Delta Dental of District of Columbia 52147 Delta Dental of Pennsylvania 23166 Delta Dental of New York 11198 Delta Dental Insurance Company (AL, FL, GA, LA, MS, MT, NV, UT, TX) 94276 American Association of Retired Personnel (AARP) AARP1 Community Partnership Program California (CPP-CA) CPPCA Texas Cook s Children CPPCC Delta Dental of Puerto Rico 660436769 7.8 PER Payer WEB Site Delta Dental's Notes for the Trading Partner: When the REF Healthcare Policy Identifier segment is required, the corresponding 1000A Payer Identification loop, PER Payer Web Site also needs to be included in the 5010 835 Remittance Advice Transaction. 835 - Companion Guide June 28, 2022 005010X221A1 835 23 Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 1000A PER PER01 Contact Function Code IC - Information Contact PER03 Communication Number Qualifier UR Uniform Resource Locator (URL) URL will be provided once it becomes available PER04 Communication Number 7.9 N1 Payee Identification Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 1000B N1 N101 Entity Identifier Code PE - Payee N102 Name Possible Values: Organization Name Individual Name (format is Last Name, First Name, Middle Name) N103 Identification Code Qualifier FI - Federal Taxpayer's Identification Number; XX - Centers for Medicare and Medicaid Services National Provider Identifier N104 Identification Code External Code List Name: 537 Description: Centers for Medicare and Medicaid Services National Provider Identifier External Code List Name: 540 Description: Centers for Medicare and Medicaid Services Plan ID Possible values: NPI from Delta Dental's system that is associated to the providers on the payment claim. May or may not be identical to the NPI from submitted claim Tax ID, when there is no NPI in Delta Dental's system that is associated to the Providers on the payment claim. 835 - Companion Guide June 28, 2022 005010X221A1 835 24 7.10 N3 Payee Address Delta Dental's Notes for the Trading Partner: Payee address from Delta Dental's system is sent. 7.11 N4 Payee City, State, Zip Code Delta Dental's Notes for the Trading Partner: Payee address from Delta Dental's system is sent. 7.12 REF Payee Additional Identification Delta Dental's Notes for the Trading Partner: This segment is generated when the NPI identifier (XX) is sent on N103 (N1 Payee Identification segment). Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 1000B REF REF01 Reference Identification Qualifier 0B - State License Number D3 - National Council for Prescription Drug Programs Pharmacy Number PQ - Payee Identification TJ - Federal Taxpayer's Identification Number TJ Federal Taxpayer s Identification Number will be used for this implementation REF02 Reference Identification External Code List Name: 307 Description: National Council for Prescription Drug Programs Pharmacy Number Tax ID from Delta Dental's system that is associated to the providers on the payment claim. 7.13 CLP Claim Payment Information Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 835 - Companion Guide June 28, 2022 005010X221A1 835 25 2100 CLP CLP01 Claim Submitter's Identifier For electronic claims (837D): Submitted Patient Control Number (PCN) For paper claims: Patient Control Number (PCN) For manually-entered claims and system generated claims without PCN: "0" (zero) CLP02 Claim Status Code 1 - Processed as Primary; 2 - Processed as Secondary; 3 - Processed as Tertiary; 4 Denied; 22 - Reversal of Previous Payment; 25 - Predetermination Pricing Only - No Payment CLP03 Monetary Amount Total Claim Charge Amount CLP04 Monetary Amount Claim Payment Amount CLP05 Monetary Amount Patient Responsibility Amount CLP06 Claim Filing Indicator Code 15 - Indemnity Insurance CLP07 Reference Identification Delta Dental-assigned Claim ID (Document Control Number DCN) CLP08 Facility Code Value 7.14 NM1 Patient Name Delta Dental's Notes for the Trading Partner: Delta Dental-assigned patient information may or may not be identical to the patient information from submitted 837D Electronic or paper claims. 835 - Companion Guide June 28, 2022 005010X221A1 835 26 Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 2100 NM1 NM101 Entity Identifier Code QC - Patient NM102 Entity Type Qualifier 1 Person NM103 Name Last or Organization Name Delta Dental will swap Last Name from submitted 837D Electronic or Paper claim if available. NM104 Name First Delta Dental will swap First Name from submitted 837D Electronic or Paper claim if available NM105 Name Middle Delta Dental will swap Middle Name from submitted 837D Electronic or Paper claims if available NM107 Name Suffix NM108 Identification Code Qualifier 34 - Social Security Number; HN - Health Insurance Claim (HIC) Number; II - Standard Unique Health Identifier for each Individual in the United States; MI - Member Identification Number; MR - Medicaid Recipient Identification Number Delta Dental will use MI - Member Identification Number NM109 Identification Code Delta Dental will swap Identification Code from submitted 837D Electronic Claims or Paper claims if available 7.15 NM1 Insured Name Delta Dental's Notes for the Trading Partner: This segment is generated when Patient is NOT the Insured. 835 - Companion Guide June 28, 2022 005010X221A1 835 27 Delta Dental-assigned patient information may or may not be identical to the patient information from submitted 837D Electronic or paper claims. Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 2100 NM1 NM101 Entity Identifier Code IL - Insured or Subscriber NM102 Entity Type Qualifier 1 - Person; 2 - Non-Person Entity NM103 Name Last or Organization Name Delta Dental will swap Last Name from submitted 837D Electronic or Paper claim if available NM104 Name First Delta Dental will swap First Name from submitted 837D Electronic or Paper claim if available NM105 Name Middle Delta Dental will swap Middle Name from submitted 837D Electronic or Paper claims if available NM107 Name Suffix NM108 Identification Code Qualifier FI - Federal Taxpayer's Identification Number; II - Standard Unique Health Identifier for each Individual in the United States; MI - Member Identification Number Delta Dental will use MI - Member Identification Number NM109 Identification Code Delta Dental will swap Identification Code from submitted 837D Electronic Claims or Paper claims if available 7.16 NM1 Service Provider Name Delta Dental's Notes for the Trading Partner: NPI is required when enrolling Providers to receive 835 ERA from Delta Dental. 835 - Companion Guide June 28, 2022 005010X221A1 835 28 Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 2100 NM1 NM101 Entity Identifier Code 82 - Rendering Provider NM102 Entity Type Qualifier 1 - Person; 2 - Non-Person Entity NM103 Name Last or Organization Name NM104 Name First NM105 Name Middle NM107 Name Suffix NM108 Identification Code Qualifier BD - Blue Cross Provider Number; BS - Blue Shield Provider Number; FI - Federal Taxpayer's Identification Number; MC - Medicaid Provider Number PC Provider Commercial Number; SL State License Number; UP - Unique Physician Identification Number (UPIN); XX - Centers for Medicare and Medicaid Services National Provider Identifier Delta Dental will use XX - Centers for Medicare and Medicaid Services National Provider Identifier NM109 Identification Code NPI from Delta Dental's system that is associated to the Rendering Provider on the claim. May or may not be identical to the NPI from submitted claim 835 - Companion Guide June 28, 2022 005010X221A1 835 29 7.17 REF Rendering Provider Identification (Loop 2100) Delta Dental's Notes for the Trading Partner: Rendering Provider Identifiers from submitted claim are returned as received. 7.18 SVC Service Payment Information Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 2110 SVC SVC02 Monetary Amount Line Item Charge Amount SVC03 Monetary Amount Line Item Payment Amount 7.19 REF Service Identification Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 2110 REF REF02 Reference Identification External Code List Name: 468 Description: Ambulatory Payment Classification Line Item Control Number from submitted claim 7.20 REF Line Control Number Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 2110 REF REF01 Reference Identification Qualifier 6R - Provider Control Number REF02 Reference Identification 7.21 REF Rendering Provider Information (2110) Delta Dental's Notes for the Trading Partner: 835 - Companion Guide June 28, 2022 005010X221A1 835 30 Service Line Rendering Provider Identifier from submitted claims are returned as received. 7.22 REF HealthCare Policy Identification Delta Dental's Notes for the Trading Partner: The REF Healthcare Policy Identifier is required to be included in the 2110 Service Payment Information loop when specific CARC values are included in a related CAS segment. Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes 2110 REF REF01 Reference Identification Qualifier 0K - Policy Form Identifying Number REF02 Reference Identification 7.23 PLB Provider Adjustments Loop ID Segment Element ID Data Element Name Codes Delta Dental Notes N A PLB PLB02 Date December 31st of the payment year Add Provider Enrollment specifications. 835 - Companion Guide June 28, 2022 005010X221A1 835 31 8 Acknowledgements Only one response will be required for each 835 transaction that is transmitted to the Trading Partners a TA1 or 999. The 835 Health Care Claim Payment Advice sent by Delta Dental must be HIPAA compliant. 8.1 999 Functional Acknowledgment When ACK (ISA14 1) is requested by Delta Dental, Exchange or Trading Partners must issue a 999 Acknowledgment for Health Care Insurance (005010X231 or 005010X231A) when an 835 fails validation of WEDI SNIP Type 1-3 HIPAA edits. Delta Dental does not expect positive acknowledgments for successful 835 transmissions and validation. The purpose of the 999 Acknowledgment (Reject) is to identify critical errors within the 835 request based on the ASC X12N 835 (version 005010X221A1) Technical Report Type 3 (TR3) guide. Delta Dental will review the 999 to determine what errors occurred. 8.2 TA1 Interchange Acknowledgment The TA1 Interchange Acknowledgement is used by the 835 transaction to communicate the rejection of a 835 transaction based on errors encountered with X12 compliance, formatting, or specific requirements of the ISA IEA Interchange segments. 835 - Companion Guide June 28, 2022 005010X221A1 835 32 Document Revision History Version Date Description of Changes Author 0.1 7 26 2013 Initial Draft Vanessa Nguyen 0.2 10 08 2013 Added Payer Specific Business Rules Limitations Vanessa Nguyen 0.3 10 16 2013 Modified several sections for clarify Bernadette Abdon 1.0 10 31 2013 Final Draft Bernadette Abdon 1.1 06 28 2022 Added section 4.3 (enrollment file notifications) Shiv Uppal 835 - Companion Guide June 28, 2022 005010X221A1 835 33 | /kaggle/input/edi-db-835-837/companion-guide-835.pdf | 797bef7c9f95e3cc46e3501cfa4c1f9c | 797bef7c9f95e3cc46e3501cfa4c1f9c_0 |
State of Washington 837 Professional Healthcare Claim Companion Guide Prepared by: CNSI August 2012 WAMMIS-CG-837P-CLAIMS-5010-01-01 Disclaimer This companion guide contains data clarifications derived from specific business rules that apply exclusively to Washington State Medicaid processing for Washington State HCA. The guide also includes useful information about sending and receiving data to and from the Washington State ProviderOne system. State of Washington ProviderOne 5010 837 Professional Companion Guide iii WAMMIS-CG-837P-CLAIMS-5010-01-01 Revision History Document revisions are maintained in this document through the Revision History Table shown below. All revisions made to this companion guide after the creation date is noted along with the date, page affected, and reason for the change. Revision Level Date Page Description Change Summary WAMMIS-CG- 837CLAIMS-5010-01-01 12 17 10 Initial Document WAMMIS-CG-837P- CLAIMS-5010-01-01 02 11 11 Review comments incorporated WAMMIS-CG-837P- CLAIMS-5010-01-01 8 20 2012 Update per ASC X12 recommendations State of Washington ProviderOne 5010 837 Professional Companion Guide iv WAMMIS-CG-837P-CLAIMS-5010-01-01 Contents Disclaimer............................................................................................................................ ii Revision History....................................................................................................................... iii 1 Introduction........................................................................................................................ 5 1.1 Document Purpose................................................................................................... 5 1.1.1 Intended Users.................................................................................................... 6 1.1.2 Relationship to HIPAA Implementation Guides.................................................... 6 1.2 Transmission Schedule............................................................................................ 6 2 Technical Infrastructure and Procedures......................................................................... 7 2.1 Technical Environment............................................................................................. 7 2.1.1 Communication Requirements............................................................................. 7 2.1.2 Testing Process................................................................................................... 7 2.1.3 Who to contact for assistance.............................................................................. 8 2.2 Upload batches via Web Interface........................................................................... 9 2.3 Set-up, Directory, and File Naming Convention.................................................... 14 2.3.1 SFTP Set-up...................................................................................................... 14 2.3.2 SFTP Directory Naming Convention.................................................................. 14 2.3.3 File Naming Convention..................................................................................... 15 2.4 Transaction Standards........................................................................................... 16 2.4.1 General Information........................................................................................... 16 2.4.2 Data Format....................................................................................................... 16 2.4.3 Data Interchange Conventions........................................................................... 17 2.4.4 17 2.4.5 Acknowledgement Procedures........................................................................... 17 2.4.6 Rejected Transmissions and Transactions......................................................... 17 3 Transaction Specifications............................................................................................. 18 5010 837 Professional Companion Guide 5 WAMMIS-CG-837P-CLAIMS-5010-01-01 1 Introduction The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) includes requirements that national standards be established for electronic health care transactions, and national identifiers for providers, health plans, and employers. This requires Washington State Health Care Authority (HCA) to adopt standards to support the electronic exchange of administrative and financial health care transactions between covered entities (health care providers, health plans, and healthcare clearinghouses). The intent of these standards is to improve the efficiency and effectiveness of the nation's health care system by encouraging widespread use of electronic data interchange standards in health care. The intent of the law is that all electronic transactions for which standards are specified must be conducted according to the standards. These standards were developed by processes that included significant public and private sector input. 1.1 Document Purpose Companion Guides are used to clarify the exchange of information on HIPAA transactions between the HCA ProviderOne system and its trading partners. HCA defines trading partners as covered entities that either submit or retrieve HIPAA batch transactions to and from ProviderOne. This Companion Guide is intended for trading partner use in conjunction with the ASC X12N Implementation Guides listed below. The ASC X12 TR3s that detail the full requirements for all HIPAA mandated transactions are available at http: store.x12.org store The Standard Implementation Guide for Claim Transaction is: Healthcare Claim: Professional (837) 005010X222 HCA has also incorporated all of the approved 837 Professional Addenda listed below. Healthcare Claim: Professional (837) 005010X222A1 5010 837 Professional Companion Guide 6 WAMMIS-CG-837P-CLAIMS-5010-01-01 1.1.1 Intended Users Companion Guides are to be used by members technical staff of trading partners who are responsible for electronic transaction file exchanges. 1.1.2 Relationship to HIPAA Implementation Guides Companion Guides are intended to supplement the HIPAA Implementation Guides for each of the HIPAA transactions. Rules for format, content, and field values can be found in the Implementation Guides. This Companion Guide describes the technical interface environment with HCA, including connectivity requirements and protocols, and electronic interchange procedures. This guide also provides specific information on data elements and the values required for transactions sent to or received from HCA. Companion Guides are intended to supplement rather than replace the standard Implementation Guide for each transaction set. The information in these documents is not intended to: Modify the definition, data condition, or use of any data element or segment in the standard Implementation Guides. Add any additional data elements or segments to the defined data set. Utilize any code or data values that are not valid in the standard Implementation Guides. Change the meaning or intent of any implementation specifications in the standard Implementation Guides. 1.2 Transmission Schedule N A 5010 837 Professional Companion Guide 7 WAMMIS-CG-837P-CLAIMS-5010-01-01 2 Technical Infrastructure and Procedures 2.1 Technical Environment 2.1.1 Communication Requirements This section will describe how trading partners can send 837 Transactions to HCA using two methods: Secure File Transfer Protocol (SFTP) ProviderOne Web Portal 2.1.2 Testing Process Completion of the testing process must occur prior to submitting electronic transactions in production to ProviderOne. Testing is conducted to ensure the following levels of HIPAA compliance: 1. Level 1 Syntactical integrity: Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. 2. Level 2 Syntactical requirements: Testing for HIPAA Implementation Guide-specific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. It will also include testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or table. Additional testing may be required in the future to verify any changes made to the ProviderOne system. Changes to the formats may also require additional testing. Assistance is available throughout the testing process. Trading Partner Testing Procedures 1. ProviderOne companion guides and trading partner enrollment package are available for download via the web at http: hrsa.dshs.wa.gov hipaa 2. The Trading Partner completes the Trading Partner Agreement and submits the signed agreement to HCA. Submit to: HCA HIPAA EDI Department PO Box 45562 Olympia, WA 98504-5562 5010 837 Professional Companion Guide 8 WAMMIS-CG-837P-CLAIMS-5010-01-01 For Questions call 1-800-562-3022 ext. 16137 3. The trading partner is assigned a Submitter ID, Domain, Logon User ID and password. 4. The trading partner submits all HIPAA test files through the ProviderOne web portal or Secure File Transfer Protocol (SFTP). Web Portal URL: https: www.waproviderone.org edi SFTP URL: sftp: ftp.waproviderone.org 5. The trading partner downloads acknowledgements for the test file from the ProviderOne web portal or SFTP. 6. If ProviderOne system generates a positive TA1 and positive 999 acknowledgements, the file is successfully accepted. The trading partner is then approved to send 837 HIPAA files in production. 7. If the test file generates a negative TA1 or negative 999 acknowledgments, then the submission is unsuccessful and the file is rejected. The trading partner needs to resolve all the errors reported on the negative TA1 or negative 999 and resubmit the file for test. Trading partners will continue to test in the testing environment until they receive a positive TA1 and positive 999. 2.1.3 Who to contact for assistance Email: hipaa-help hca.wa.gov o All emails result in the assignment of a Ticket Number for problem tracking Information required for initial email: o Name o Phone Number o Email Address o 7 digit ProviderOne ID Number o NPI o HIPAA File Name o Detailed Description of Issue o HIPAA Transaction Information required for follow up call(s): o Assigned Ticket Number 5010 837 Professional Companion Guide 9 WAMMIS-CG-837P-CLAIMS-5010-01-01 2.2 Upload batches via Web Interface Log into the ProviderOne Portal, select the appropriate security profile and the following options will be viewable to the user: Scroll down to the HIPAA heading to manage the submission and retrieval of HIPAA transactions. 5010 837 Professional Companion Guide 10 WAMMIS-CG-837P-CLAIMS-5010-01-01 Follow these steps to upload a HIPAA file: Click on the Upload link On the file upload page click on the Browse button to attach HIPAA file from local file system. After selecting the file from the local file system, press OK to start the upload. 5010 837 Professional Companion Guide 11 WAMMIS-CG-837P-CLAIMS-5010-01-01 Once the Ok button is selected, a confirmation message is displayed on the screen along with transmission details. This message only means the file was submitted. To determine if the file was successfully validated and processed go back to the ProviderOne main page, select Retrieve HIPAA Batch Response, and follow these steps: Select 837 from the Transaction Type drop down menu There are 3 filter boxes available that contain the following filter criteria that you can use to search for your submitted HIPAA file o File Name o ProviderOne ID o Response Date o Upload Sent Date An example of a search would be Your ProviderOne ID o The are considered wildcard searches Click on Go once you entered all the necessary filters. Keep in mind you can enter up to 3 filters to refine the search of your submitted HIPAA transaction All the HIPAA transactions that match your search criteria should return on the page Click on the down arrow in the Upload Sent Date column to sort the most current files to least current files Now look for Accepted or Rejected in the Acknowledgement Status Column. Accepted means the file will be processed. Rejected means the file will not be processed due to errors. Partial means some of the file was processed but not all of it due to errors. 5010 837 Professional Companion Guide 12 WAMMIS-CG-837P-CLAIMS-5010-01-01 The Custom Report is a user friendly report that lets you know what caused the file to reject Be sure to scroll to the right side of the screen to see all of the transactions available. 5010 837 Professional Companion Guide 13 WAMMIS-CG-837P-CLAIMS-5010-01-01 5010 837 Professional Companion Guide 14 WAMMIS-CG-837P-CLAIMS-5010-01-01 2.3 Set-up, Directory, and File Naming Convention 2.3.1 SFTP Set-up Trading partners can email hipaa-help hca.wa.gov for information on establishing connections through the SFTP server. Upon completion of set-up, they will receive additional instructions on SFTP usage. 2.3.2 SFTP Directory Naming Convention There would be two categories of folders under Trading Partner s SFTP folders: 1. TEST Trading Partners should submit and receive their test files under this root folder 2. PROD Trading Partners should submit and receive their production files under this root folder Following folder will be available under TEST PROD folder within SFTP root of the Trading Partner: HIPAA_Inbound - This folder should be used to drop the HIPAA Inbound files that needs to be submitted to HCA HIPAA_Ack - Trading partner should look for acknowledgements to the files submitted in this folder. TA1, 999 and custom report will be available for all the files submitted by the Trading Partner HIPAA_Outbound HIPAA outbound transactions generated by HCA will be available in this folder HIPAA_Error Any inbound file that is not processed, HIPAA compliant, or is not recognized by ProviderOne will be moved to this folder HIPAA Working There is no functional use for this folder at this time 5010 837 Professional Companion Guide 15 WAMMIS-CG-837P-CLAIMS-5010-01-01 Folder structure will appear as: 2.3.3 File Naming Convention The HIPAA Subsystem Package is responsible for assisting ProviderOne activities related to Electronic Transfer and processing of Health Care and Health Encounter Data, with a few exceptions or limitations. HIPAA files are named: For Inbound transactions: HIPAA. TPId. datetimestamp. originalfilename. dat Example of file name: HIPAA.101721500.122620072100_P_1.dat TPId is the Trading Partner Id datetimestamp is the Date timestamp originalfilename is the original file name which is submitted by the trading partner. All HIPAA submitted files MUST BE.dat files or they will not be processed 5010 837 Professional Companion Guide 16 WAMMIS-CG-837P-CLAIMS-5010-01-01 2.4 Transaction Standards 2.4.1 General Information HIPAA standards are specified in the Implementation Guide for each mandated transaction and modified by authorized Addenda. Currently, the 837 transaction has one Addendum. This Addendum has been adopted as final and is incorporated into HCA requirements. An overview of requirements specific to the transaction can be found in the 837 Implementation Guide. Implementation Guides contain information related to: Format and content of interchanges and functional groups Format and content of the header, detailer and trailer segments specific to the transaction Code sets and values authorized for use in the transaction Allowed exceptions to specific transaction requirements Transmission sizes are limited based on two factors: Number of Segments Records allowed by HCA HCA file size limitations HCA limits the size of the transaction (ST-SE envelope) to a maximum of 5,000 CLM segments. HCA limits a file size to 50 MB while uploading HIPAA files through the ProviderOne web portal and 100 MB through SFTP. 2.4.2 Data Format Delimiters The ProviderOne will use the following delimiters on outbound transactions: Data element separator - Asterisk ( ) Sub-element Separator - colon (: ) Segment Terminator - Tilde ( ) 5010 837 Professional Companion Guide 17 WAMMIS-CG-837P-CLAIMS-5010-01-01 Phone Numbers Phone numbers are presented as contiguous number strings, without dashes or parenthesis markers. For example, the phone number (800) 555-1212 should be presented as 8005551212. Area codes should always be included. 2.4.3 Data Interchange Conventions When accepting 837 Healthcare Claim transactions from trading partners, HCA follows HIPAA standards. These standards involve Interchange (ISA IEA) and Functional Group (GS GE) Segments or outer envelopes. All 837 Transactions should follow the HIPAA guideline. Please refer to the 837 Implementation Guide for ISA IEA envelop, GS GE functional group and ST SE transaction specifications. Specific information on how individual data elements are populated by HCA on ISA IEA and GS GE envelopes are shown in the table beginning later in this section. The ISA IEA Interchange Envelope, unlike most ASC X12 data structures has fixed field length. The entire data length of the data element should be considered and padded with spaces if the data element length is less than the field length. 2.4.4 Acknowledgement Procedures Once the file is submitted by the trading partner and is successfully received by the ProviderOne system, a response in the form of TA1 and 999 acknowledgment transactions will be placed in appropriate folder (on the SFTP server) of the trading partner. The ProviderOne system generates positive TA1 and positive 999 acknowledgements, if the submitted HIPAA file meets HIPAA standards related to syntax and data integrity. For files, which do not meet the HIPAA standards a negative TA1 and or negative 999 are generated and sent to the trading partner. 2.4.5 Rejected Transmissions and Transactions 837 Healthcare Claims will be rejected if the file does not meet HIPAA standards for syntax, data integrity and structure (Strategic National Implementation Process (SNIP) type 1 and 2). 5010 837 Professional Companion Guide 18 WAMMIS-CG-837P-CLAIMS-5010-01-01 3 Transaction Specifications 837 PROFESSIONAL Page Loop Segment Data Element Element Name Comments INTERCHANGE CONTROL HEADER Appendix C.4 ENVELOPE ISA 01 Authorization Information Qualifier Please use '00' Appendix C.4 ENVELOPE ISA 03 Security Information Qualifier Please use '00' Appendix C.4 ENVELOPE ISA 05 Interchange ID Qualifier Please use 'ZZ' Appendix C.4 ENVELOPE ISA 06 Interchange Sender ID Please use the 9-digit ProviderOne ID followed by spaces Appendix C.5 ENVELOPE ISA 07 Interchange ID Qualifier Please use 'ZZ' Appendix C.5 ENVELOPE ISA 08 Interchange Receiver ID Please enter '77045' followed by spaces Appendix C.5 ENVELOPE ISA 11 Interchange Control Standards Identifier Please Use ' ' 5010 837 Professional Companion Guide 19 WAMMIS-CG-837P-CLAIMS-5010-01-01 Appendix C.6 ENVELOPE ISA 16 Component Element Separator Please use ':' FUNCTIONAL GROUP HEADER Appendix C.7 ENVELOPE GS 02 Application Sender s Code Please use the 9-digit ProviderOne ID. This should be same as ISA06 and Loop 1000A, Data Element NM109 Appendix C.7 ENVELOPE GS 03 Application Receiver s Code Please use '77045' Beginning of Hierarchical Transaction 71 HEADER BHT 02 Transaction Set Purpose Code Please use '00' 72 HEADER BHT 06 Claim or Encounter Indicator Transaction Type Code Please use CH Loop ID 1000A - Submitter Name 75 1000A NM1 09 Identification Code Please use the 9-digit ProviderOne ID This should be same as ISA06 and GS02 Loop ID 1000B - Receiver Name 80 1000B NM1 03 Name Last or Organization Name Please use 'WA State HCA' 80 1000B NM1 09 Identification Code Please use 77045 5010 837 Professional Companion Guide 20 WAMMIS-CG-837P-CLAIMS-5010-01-01 Loop ID 2000A - Billing Provider Specialty Information 83 2000A PRV NOTE: HCA requires the PRV segment to be submitted as the Taxonomy Code impacts adjudication Loop ID 2000B - Subscriber Information 119 2000B SBR 09 Claim Filing Indicator Code Please use 'MC' Loop ID 2010BA - Subscriber Name 123 2010BA NM1 09 Identification code Please enter 11 digit ProviderOne Client ID ProviderOne Client ID is 9 numeric digits followed by 'WA' Example is 123456789WA Loop ID 2010BA - Subscriber Demographic Information 127 2010BA DMG NOTE: HCA requires the DMG segment to be submitted as the patient is always the subscriber Loop ID 2010BB - Payer Name 134 2010BB NM1 03 Name Last or Organization Name Please use 'WA State HCA' 134 2010BB NM1 09 Identification Code Please use '77045' 5010 837 Professional Companion Guide 21 WAMMIS-CG-837P-CLAIMS-5010-01-01 Payer Address 135 2010BB N3 01 Address Information Please use 'Claims Processing' 135 2010BB N3 02 Address Information Please use 'PO BOX 9248' Payer City State Zip Code 136 2010BB N4 01 City Name Please use 'Olympia' 136 2010BB N4 02 State or Province Code Please use 'WA' 137 2010BB N4 03 Postal Code Please use '98504' Loop ID 2300 - Payer Claim Control Number 196 2300 REF 02 Reference Identification Please enter the 18 digit Transaction Control Number (TCN) of claim when CLM05-3 indicates the claim is an replacement or void Loop ID 2310B - Rendering Provider Specialty Information 265 2310B PRV NOTE: If the Rendering Provider NPI is submitted HCA requires the PRV segment to be submitted as the Taxonomy Code impacts adjudication Loop ID 2320 - Other Subscriber Information 298 2320 SBR 09 Claim filing indicator code Use 'MB' for provider submitted Medicare Part B Crossover Claims | /kaggle/input/edi-db-835-837/837-Professional-CG-2012.pdf | ed32b4253a0d4f41fd4ddee945072c87 | ed32b4253a0d4f41fd4ddee945072c87_0 |
State of Washington 837 Professional and Institutional Encounter Data Companion Guide Prepared by: CNSI WAMMIS-CG837ENC-5010-01-12 November 2023 Disclaimer This companion guide contains data clarifications derived from specific business rules that apply exclusively to Washington State Medicaid processing for Washington State HCA. The guide also includes useful information about sending and receiving data to and from the Washington State ProviderOne system. State of Washington ProviderOne 5010 837 Encounter Companion Guide iii WAMMIS-CG-837ENC-5010-01-12 Revision History Documented revisions are maintained in this document through the use of the Revision History Table shown below. All revisions made to this companion guide after the creation date are noted along with the date, page affected, and reason for the change. Revision Level Date Page Description Change Summary WAMMIS-CG837ENC- 5010-01-02 12 27 10 Initial Document WAMMIS-CG837ENC- 5010-01-03 02 02 2012 Version Number updated as a result of changes listed below Professional Encounter Functional Group Header GS02 02 02 2012 Correction Changed element description to read, Please use the 9-digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A Data Element NM109 e.g. 1234567AA Professional Encounter Loop 1000A Submitter Name 02 02 2012 Correction NM109 Removed followed by spaces from instructions Professional Encounter Loop 2010AA Billing Provider Name 02 02 2012 Correction NM102 Changed description to read, Please use the appropriate code NM103 Changed description to read, Enter the Organization Name or the Last Name of the provider who billed the MCO or RSN Professional Encounter Loop 2010BA Subscriber City State Zip Code 02 02 2012 Correction Removed identified use of element N404 Country Code Professional Encounter Loop 2010BB Billing Provider Secondary Identification 02 02 2012 Correction Corrected Loop reference for elements REF01 and REF02 to read 2010BB. Previously elements were referenced to Loop 2010 AA Professional Encounter Loop 2410 Drug Information -LIN Segments -CTP Segments 02 02 2012 Addition Added situation reference to use of Loop 2410 Drug Information when required for Managed Care Encounter submission State of Washington ProviderOne 5010 837 Encounter Companion Guide iv WAMMIS-CG-837ENC-5010-01-12 Institutional Encounter Functional Group Header GS02 02 02 2012 Correction Changed element description to read, Please use the 9-digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A Data Element NM109 e.g. 1234567AA Institutional Encounter Functional Group Header GS02 02 02 2012 Correction Changed element description to read, Please use the 9-digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A Data Element NM109 e.g. 1234567AA Institutional Encounter Loop 1000A Submitter Name 02 02 2012 Correction NM109 Removed followed by spaces from instructions Institutional Encounter Loop 2010AA Billing Provider Name 02 02 2012 Correction NM103 Changed description to read, Enter the Organization Name or the Last Name of the provider who billed the MCO or RSN Institutional Encounter Loop 2010BB 02 02 2012 Correction Payer Name Title incorrectly reference Loop 2010BC. Technical Specifications have been updated to correctly reference 2010BB Institutional Encounter Loop 2410 Drug Information -LIN Segments -CTP Segments 02 02 2012 Addition Added situation reference to use of Loop 2410 Drug Information when required for Managed Care Encounter submission WAMMIS-CG837ENC- 5010-01-04 02 27 2012 Version number updated due to the inclusion of full Companion Guide Boilerplate information WAMMIS-CG837ENC- 5010-01-05 06 2013 Update per ASC X12 recommendations WAMMIS-CG837ENC- 5010-01-06 06 01 2017 Updated to reflect additional HCP requirements for encounter submissions Updated to reflect use of Loop 2400, data elements HCP11 and HCP12 for 837 Professional Encounters State of Washington ProviderOne 5010 837 Encounter Companion Guide v WAMMIS-CG-837ENC-5010-01-12 Updated to reflect use of Loop 2300 and 2400, data elements HCP11 and HCP12 for 837 Institutional Encounters WAMMIS-CG837ENC- 5010-01-07 11 07 2018 Addition Updated to add Agency Number Site ID WAMMIS-CG837ENC- 5010-01-07 11 07 2018 Addition Updated to add requirement for Evidence-Based Practice (EBP) codes WAMMIS-CG837ENC- 5010-01-07 11 07 2018 Updates Updated references for Regional Support Network (RSN) to Behavioral Health Organization (BHO) WAMMIS-CG837ENC- 5010-01-07 3 13 2019 Updates Changed reference from Agency Number Site ID to Site-Specific, Department of Health Licensure Number WAMMIS-CG837ENC- 5010-01-07 3 13 2019 Addition Updated to reflect use of Loop 2300 for Prior Authorization WAMMIS-CG837ENC- 5010-01-08 4 14 2020 Updates Updated verbiage, screen prints and web links. WAMMIS-CG837ENC- 5010-01-09 5 27 2022 Addition Addition of HCP 03 segments in Professional and Institutional at both Header and Line levels WAMMIS-CG837ENC- 5010-01-10 09 01 2022 Update Update instructions in the comments sections for 2000B SBR03 and 2010BA NM109 WAMMIS-CG837ENC- 5010-01-11 06 26 2023 Addition Addition of requirements for Electronic Visit Verification (EVV) data for Home Health services. WAMMIS-CG837ENC- 5010-01-12 10 17 2023 Addition Addition of Rendering Provider to 837I to meet Electronic Visit Verification (EVV) data for Home Health services requirements. State of Washington ProviderOne 5010 837 Encounter Companion Guide vi WAMMIS-CG-837ENC-5010-01-12 Contents Disclaimer............................................................................................................................ ii Revision History....................................................................................................................... iii 1 Introduction........................................................................................................................ 7 1.1 Document Purpose................................................................................................... 7 1.1.1 Intended Users.................................................................................................... 8 1.1.2 Relationship to HIPAA Implementation Guides.................................................... 8 1.2 Transmission Schedule............................................................................................ 8 2 Technical Infrastructure and Procedures......................................................................... 9 2.1 Technical Environment............................................................................................. 9 2.1.1 Communication Requirements............................................................................. 9 2.1.2 Testing Process................................................................................................... 9 2.1.3 Who to contact for assistance............................................................................ 10 2.2 Upload batches via Web Interface......................................................................... 11 2.3 Set-up, Directory, and File Naming Convention.................................................... 16 2.3.1 SFTP Set-up...................................................................................................... 16 2.3.2 SFTP Directory Naming Convention.................................................................. 16 2.3.3 File Naming Convention..................................................................................... 17 2.4 Transaction Standards........................................................................................... 18 2.4.1 General Information........................................................................................... 18 2.4.2 Data Format....................................................................................................... 18 2.4.3 Data Interchange Conventions........................................................................... 19 2.4.4 Acknowledgement Procedures........................................................................... 19 2.4.5 Rejected Transmissions and Transactions......................................................... 19 3 Transaction Specifications.................................................................................................. 20 State of Washington ProviderOne 5010 837 Encounter Companion Guide 7 WAMMIS-CG-837ENC-5010-01-12 1 Introduction The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) includes requirements that national standards be established for electronic health care transactions, and national identifiers for providers, health plans, and employers. This requires Washington State Health Care Authority (HCA) to adopt standards to support the electronic exchange of administrative and financial health care transactions between covered entities (health care providers, health plans, and healthcare clearinghouses). The intent of these standards is to improve the efficiency and effectiveness of the nation's health care system by encouraging widespread use of electronic data interchange standards in health care. The intent of the law is that all electronic transactions for which standards are specified must be conducted according to the standards. These standards were developed by processes that included significant public and private sector input. Encounters are not HIPAA named transactions and the 837I and 837P Implementation Guides were used as a foundation to construct the standardized HCA encounter reporting process. 1.1 Document Purpose Companion Guides are used to clarify the exchange of information on HIPAA transactions between the HCA ProviderOne system and its trading partners. HCA defines trading partners as covered entities that either submit or retrieve HIPAA batch transactions to and from ProviderOne. This Companion Guide is intended for trading partner use in conjunction with the ASC X12N Implementation Guides listed below. The ASC X12 TR3s that detail the full requirements for all HIPAA mandated transactions are available at http: store.x12.org store The Standard Implementation Guides for Claim Transaction is: Healthcare Claim (Encounters): Professional (837) 005010X222 Healthcare Claim (Encounters): Institutional (837) 005010X223 HCA has also incorporated all of the approved 837 Professional and 837 Institutional Addenda listed below. Healthcare Claim (Encounters): Professional (837) 005010X222A1 Healthcare Claim (Encounters): Institutional (837) 005010X223A1 Healthcare Claim (Encounters): Institutional (837) 005010X223A2 State of Washington ProviderOne 5010 837 Encounter Companion Guide 8 WAMMIS-CG-837ENC-5010-01-12 1.1.1 Intended Users Companion Guides are to be used by members technical staff of trading partners who are responsible for electronic transaction file exchanges. 1.1.2 Relationship to HIPAA Implementation Guides Companion Guides are intended to supplement the HIPAA Implementation Guides for each of the HIPAA transactions. Rules for format, content, and field values can be found in the Implementation Guides. This Companion Guide describes the technical interface environment with HCA, including connectivity requirements and protocols, and electronic interchange procedures. This guide also provides specific information on data elements and the values required for transactions sent to or received from HCA. Companion Guides are intended to supplement rather than replace the standard Implementation Guide for each transaction set. The information in these documents is not intended to: Modify the definition, data condition, or use of any data element or segment in the standard Implementation Guides. Add any additional data elements or segments to the defined data set. Utilize any code or data values that are not valid in the standard Implementation Guides. Change the meaning or intent of any implementation specifications in the standard Implementation Guides. 1.2 Transmission Schedule N A State of Washington ProviderOne 5010 837 Encounter Companion Guide 9 WAMMIS-CG-837ENC-5010-01-12 2 Technical Infrastructure and Procedures 2.1 Technical Environment 2.1.1 Communication Requirements This section will describe how trading partners can send 837 Encounters Transactions to HCA using 2 methods: Secure File Transfer Protocol (SFTP) ProviderOne Web Portal 2.1.2 Testing Process Completion of the testing process must occur prior to submitting electronic transactions in production to ProviderOne. Testing is conducted to ensure the following levels of HIPAA compliance: 1. Level 1 Syntactical integrity: Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. 2. Level 2 Syntactical requirements: Testing for HIPAA Implementation Guide-specific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. It will also include testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or table. Additional testing may be required in the future to verify any changes made to the ProviderOne system. Changes to the ANSI formats may also require additional testing. Assistance is available throughout the testing process. Trading Partner Testing Procedures 1. ProviderOne companion guides and trading partner enrollment package are available for download via the web at: HIPAA Electronic Data Interchange (EDI) Washington State Health Care Authority 2. The Trading Partner completes the Trading Partner Agreement and submits the signed agreement to HCA. Submit to: HCA HIPAA EDI Department 626 8th Avenue SE PO Box 45564 State of Washington ProviderOne 5010 837 Encounter Companion Guide 10 WAMMIS-CG-837ENC-5010-01-12 Olympia, WA 98504-5564 For Questions call 1-800-562-3022 ext 16137 3. The trading partner is assigned a Submitter ID, Domain, Logon User ID and password. 4. The trading partner submits all HIPAA test files through the ProviderOne web portal or Secure File Transfer Protocol (SFTP). Web Portal URL: https: www.waproviderone.org edi SFTP URL: sftp: ftp.waproviderone.org 5. The trading partner downloads acknowledgements for the test file from the ProviderOne web portal or SFTP. 6. If ProviderOne system generates a positive TA1 and positive 999 acknowledgement, the file is successfully accepted. The trading partner is then approved to send X12N 837 Encounters files in production. 7. If the test file generates a negative TA1 or negative 999 acknowledgment, then the submission is unsuccessful and the file is rejected. The trading partner needs to resolve all the errors that are reported on the negative TA1 or negative 999 and resubmit the file for test. Trading partners will continue to test in the testing environment until they receive a positive TA1 and positive 999. 2.1.3 Who to contact for assistance Email: HIPAA-Help hca.wa.gov o All emails result in the assignment of a Ticket Number for problem tracking Information required for initial email: o Name o Phone Number o Email Address o 7 Digit domain ProviderOne ID o Transaction you are inquiring about o File Name o Detailed description of concern Information required for follow up call(s): o Assigned Ticket Number State of Washington ProviderOne 5010 837 Encounter Companion Guide 11 WAMMIS-CG-837ENC-5010-01-12 2.2 Upload batches via Web Interface Once logged into the ProviderOne Portal, select the Admin Tab and the following options will be presented to the user: Scroll down to the HIPAA options on the right side to manage the HIPAA transactions. State of Washington ProviderOne 5010 837 Encounter Companion Guide 12 WAMMIS-CG-837ENC-5010-01-12 In the HIPAA section, the user can Submit file and Retrieve Acknowledgement Response as shown below: State of Washington ProviderOne 5010 837 Encounter Companion Guide 13 WAMMIS-CG-837ENC-5010-01-12 In order to upload a file, the following steps are followed: Click on the Upload button to upload a HIPAA file On file upload page click on the Browse button to attach HIPAA file from local file system. After selecting the file from the local file system, press OK to start the upload. State of Washington ProviderOne 5010 837 Encounter Companion Guide 14 WAMMIS-CG-837ENC-5010-01-12 Once the file is uploaded to the ProviderOne system success failure message is displayed on the screen along with transmission details. State of Washington ProviderOne 5010 837 Encounter Companion Guide 15 WAMMIS-CG-837ENC-5010-01-12 Select Retrieve Acknowledgement Response option from the HIPAA screen to retrieve Acknowledgements Responses (TA1, 999, 271, 277, 820, 834, 835, or 277U) as shown below: State of Washington ProviderOne 5010 837 Encounter Companion Guide 16 WAMMIS-CG-837ENC-5010-01-12 2.3 Set-up, Directory, and File Naming Convention 2.3.1 SFTP Set-up Trading partners can contact HIPAA-help hca.wa.gov for information on establishing connections through the FTP server. Upon completion of set-up, they will receive additional instructions on FTP usage. 2.3.2 SFTP Directory Naming Convention There would be two categories of folders under Trading Partner s SFPT folders: 1. TEST Trading Partners should submit and receive their test files under this root folder 2. PROD Trading Partners should submit and receive their production files under this root folder 3. README This folder will include messages regarding password update requirements, outage information and general SFTP messages. Following folder will be available under TEST PROD folder within SFTP root of the Trading Partner: HIPAA_Inbound - This folder should be used to drop the Inbound files that need to be submitted to HCA HIPAA_Ack - Trading partner should look for acknowledgements to the files submitted in this folder. TA1, 999 and custom error report will be available for all the files submitted by the Trading Partner HIPAA_Outbound X12 outbound transactions generated by HCA will be available in this folder HIPAA_Error Any inbound file that is not HIPAA compliant or is not recognized by ProviderOne will be moved to this folder HIPAA Working There is no functional use for this folder at this time State of Washington ProviderOne 5010 837 Encounter Companion Guide 17 WAMMIS-CG-837ENC-5010-01-12 Folder structure will appear as: 2.3.3 File Naming Convention The HIPAA Subsystem Package is responsible for assisting ProviderOne activities related to Electronic Transfer and processing of Health Care and Health Encounter Data, with a few exceptions or limitations. HIPAA files are named: For Inbound transactions: HIPAA. TPId. datetimestamp. originalfilename. dat Example of file name: HIPAA.101721500.122620072100_P_1.dat TPId is the Trading Partner Id datetimestamp is the Date timestamp originalfilename is the original file name which is submitted by the trading partner. All HIPAA submitted files MUST BE.dat files or they will not be processed State of Washington ProviderOne 5010 837 Encounter Companion Guide 18 WAMMIS-CG-837ENC-5010-01-12 2.4 Transaction Standards 2.4.1 General Information HIPAA standards are specified in the Implementation Guide for each mandated transaction and modified by authorized Addenda. Encounter Transactions utilize both the 837P and 837I Implementation Guides. Currently, the 837P has one Addendum and the 837I transaction has two Addenda. These Addenda have been adopted as final and are incorporated into HCA requirements. An overview of requirements specific to the transaction can be found in the 837P and 837I Implementation Guides. Implementation Guides contain information related to: Format and content of interchanges and functional groups Format and content of the header, detailer and trailer segments specific to the transaction Code sets and values authorized for use in the transaction Allowed exceptions to specific transaction requirements Transmission sizes are limited based on two factors: Number of Segments Records allowed by HIPAA Standards HCA file size limitations HIPAA standards limits the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. HCA limits a file size to 50 MB while uploading HIPAA files through the ProviderOne web portal and 100 MB through FTP. 2.4.2 Data Format Delimiters The ProviderOne will use the following delimiters on outbound transactions: Data element separator, Asterisk, ( ) Sub-element Separator, Colon, (: ) State of Washington ProviderOne 5010 837 Encounter Companion Guide 19 WAMMIS-CG-837ENC-5010-01-12 Segment Terminator, Tilde, ( ) Repetition Separator, Caret, ( ) 2.4.3 Data Interchange Conventions When accepting 837 Encounters transactions from trading partners, HCA follows HIPAA standards. These standards involve Interchange (ISA IEA) and Functional Group (GS GE) Segments or outer envelopes. All 837 Encounters Transactions should follow the HIPAA guideline. Please refer to the 837 Implementation Guide for ISA IEA envelop, GS GE functional group and ST SE transaction specifications. The ISA IEA Interchange Envelope, unlike most ASC X12 data structures has fixed field length. The entire data length of the data element should be considered and padded with spaces if the data element length is less than the field length. 2.4.4 Acknowledgement Procedures Once the file is submitted by the trading partner and is successfully received by the ProviderOne system, a response in the form of TA1 and 999 acknowledgment transactions will be placed in appropriate folder (on the SFTP server) of the trading partner. The ProviderOne system generates positive TA1 and positive 999 acknowledgements, if the submitted HIPAA file meets HIPAA standards related to syntax and data integrity. For files that do not meet the HIPAA standards, a negative TA1 and or negative 999 are generated and sent to the trading partner. 2.4.5 Rejected Transmissions and Transactions 837 Encounters will be rejected if the file does not meet HIPAA standards for syntax, data integrity and structure (Strategic National Implementation Process (SNIP) type 1 and 2). State of Washington ProviderOne 5010 837 Encounter Companion Guide 20 WAMMIS-CG-837ENC-5010-01-12 3 Transaction Specifications 837 Professional Encounters Page Loop Segment Data Element Element Name Comments Interchange Control Header (ISA) App.C Envelope ISA 01 Authorization Information Qualifier Please use '00'. App.C Envelope ISA 03 Security Information Qualifier Please use '00'. App.C Envelope ISA 05 Interchange ID Qualifier Please use 'ZZ'. App.C Envelope ISA 06 Interchange Sender ID Please use the nine-digit alphanumeric submitter ID assigned during the enrollment process, followed by spaces (e.g. 1234567AA). App.C Envelope ISA 07 Interchange ID Qualifier Please use 'ZZ'. App.C Envelope ISA 08 Interchanger Receiver ID Please enter '77045' followed by spaces. App.C Envelope ISA 11 Repetition Separator Please use. App.C Envelope ISA 16 Component Element Separator Please use ':'. Functional Group Header (GS) App.C Envelope GS 02 Application Sender Code Please use the nine-digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A, Data Element NM109 (e.g. 1234567AA). App.C Envelope GS 03 Applications Receivers Code Please use '77045'. Beginning Hierarchical Transaction (BHT) State of Washington ProviderOne 5010 837 Encounter Companion Guide 21 WAMMIS-CG-837ENC-5010-01-12 71 Header BHT 02 Transaction Set Purpose Code Please use 00. 72 Header BHT 06 Claim or Encounter Indicator Please use RP for encounter. Submitter Name (Loop 1000A) 75 1000A NM1 09 Submitter ID Please use the nine-digit alphanumeric submitter ID assigned during the enrollment process (e.g. 1234567AA). This should be the same as ISA06 and GS02. Receiver Name (1000B) 80 1000B NM1 03 Receiver Name Please enter WA State HCA. 80 1000B NM1 09 Receiver Primary Identifier Please use 77045. Billing Provider Specialty Information (2000A) 83 2000A PRV NOTE: For medical and behavioral health encounters this must always be the taxonomy for the provider who billed the MCO. Billing Provider Name (2010AA) 88 2010AA NM1 NOTE: For medical and behavioral health encounters this must always be the provider who billed the MCO. Subscriber Information (Loop 2000B) 117 2000B SBR 03 Reference Identification SBR03 is not used for medical or behavioral health (BH) encounters submitted by MCOs. For encounters submitted by ASOs, the ASO unique consumer ID MUST be entered (even if already entered in NM109). 118 2000B SBR 09 Claim Filing Indicator Code. Please enter MC. Subscriber Name (Loop 2010BA) State of Washington ProviderOne 5010 837 Encounter Companion Guide 22 WAMMIS-CG-837ENC-5010-01-12 123 2010BA NM1 09 Identification Code For medical and behavioral health (BH) encounters submitted by MCOs for Medicaid clients, please enter the ProviderOne Client ID. This ID is 11 digits in length and is alphanumeric in the following format: nine numeric digits followed by WA. Example: 123456789WA For encounters submitted by ASOs, one of the following MUST be entered: 1) The ProviderOne Client ID; or 2) The ASO unique consumer ID (i.e., this is the same information reported in Loop 2000B SBR03.) Subscriber Address (Loop 2010BA) 124 2010BA N3 NOTE: For homeless clients please enter unknown in N301. Subscriber City State ZIP Code (Loop 2010BA) 125 2010BA N4 NOTE: For homeless clients please enter the city, state and zip code for the service provider. Subscriber Demographic Information (Loop 2010BA) 127 2010BA DMG NOTE: HCA requires the DMG segment to be submitted as the patient is always the subscriber. Payer Name (Loop 2010BB) 133 2010BB NM1 03 Payer Name Name last Organization Name Please enter WA State HCA. 133 2010BB NM1 09 Payer ID Please use 77045. Billing Provider Secondary Identification (Loop 2010BB) 140 2010BB REF Note: This segment is used to identify the MCO and ASO ProviderOne ID. State of Washington ProviderOne 5010 837 Encounter Companion Guide 23 WAMMIS-CG-837ENC-5010-01-12 140 2010BB REF 01 Billing Provider Secondary ID Qualifier Please use G2 to identify the ProviderOne ID. 141 2010BB REF 02 Billing Provider Secondary ID Please enter nine-digit alphanumeric ProviderOne ID. Claim Information (Loop 2300) Date Admission (Loop 2300) 176 2300 DTP NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. Date Discharge (Loop 2300) 177 2300 DTP NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. Prior Authorization (Loop 2300) REF 01 Reference Identification Qualifier Please enter G1. REF 02 Reference Identification Please enter the nine-digit Evidence-Based Practice (EBP) code. Payer Claim Control Number (Loop 2300) 196 2300 REF 02 Reference Identification Please enter the 18 digit Transaction Control Number (TCN) of claim when CLM05-3 indicates the claim is a replacement or void. Medical Record Number (Loop 2300) 204 2300 REF Used only for ASO submitted encounters when appropriate. Not used for medical or BH encounters submitted by MCOs. Claim Pricing Repricing Information (Loop 2300) State of Washington ProviderOne 5010 837 Encounter Companion Guide 24 WAMMIS-CG-837ENC-5010-01-12 253 2300 HCP NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. 253 2300 HCP 01 Pricing Repricing Methodology Please enter based on how the MCO reimbursed the claim: 00 Claim denied by MCO; or 02 MCO paid a non-capitated amount; or 07 MCO paid based on a capitation arrangement. 253 2300 HCP 02 Monetary Amount Total Claim Paid Amount MCOs to report the Amount Paid (amount that MCO paid) to the Billing Pay-to provider or 0.00 if MCO denied the claim. 253 2300 HCP 03 Monetary Amount MCO Allowed Amount (Usual and Customary) Referring Provider Name (Loop 2310A) 258 2310A NM1 NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. Referring Provider Secondary Identification (Loop 2310A) 260 2310A REF NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. Rendering Provider Name (Loop 2310B) 263 2310B NM1 NOTE: Used only for medical and BH encounters submitted by MCOs. Not used for encounters submitted by ASOs as professional encounters are not reported below the CMHA level. Service Facility Location Secondary Identification (Loop 2310C) State of Washington ProviderOne 5010 837 Encounter Companion Guide 25 WAMMIS-CG-837ENC-5010-01-12 275 2310C REF 01 Reference Identification Qualifier Please enter G2. 276 2310C REF 02 Reference Identification Please enter the site-specific, Department of Health (DOH) License Number. Provide just the certification number and do not include preceding characters (i.e., BHA.FS.60872639). DO NOT use the DSHS-DBHR Legacy License Number. Other Subscriber Information (Loop 2320) 298 2320 SBR 09 Claim Filing Indicator Code Please use 'MB' when submitting Medicare Crossover Claims; otherwise use MC. Line Note (Loop 2400) 465 2400 NTE 01 Note Reference Code MCO use appropriate code. ASO use ADD. 465 2400 NTE 02 Line Note Text MCO use as needed per the IG. ASO refer to BHDS data dictionary. Line Pricing Re-pricing Information (Loop 2400) 413 2400 HCP NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. 413 2400 HCP 01 Pricing Re- pricing Methodology Please enter based on how the MCO reimbursed the claim: 00 Claim denied by MCO; or 02 MCO paid a non-capitated amount; or 07 MCO paid based on a capitation arrangement. 413 2400 HCP 02 Monetary Amount Total Claim Paid Amount MCOs to report the Amount Paid (amount that MCO paid) to the Billing Pay-to provider or 0.00 if MCO denied the claim. State of Washington ProviderOne 5010 837 Encounter Companion Guide 26 WAMMIS-CG-837ENC-5010-01-12 413 2400 HCP 03 Monetary Amount MCO Allowed Amount (Usual and Customary) 420 2400 HCP 11 Unit or Basis For Measurement Code MCOs to use appropriate unit qualifier per IG. 420 2400 HCP 12 Quantity MCOs to report number of paid units. Rendering Provider Name (Loop 2420A) 431 2420A NM1 NOTE: Not used for ASO submitted encounters as professional encounters are not reported below the CMHA level. Service Facility Location Secondary Identification (Loop 2420C) 447 2420C REF 01 Reference Identification Qualifier Please enter G2. 448 2420C REF 02 Reference Identification Please enter the site-specific, Department of Health (DOH) License Number. Provide just the certification number and do not include preceding characters (i.e., BHA.FS.60872639). DO NOT use the DSHS-DBHR Legacy License Number. 837 Institutional Encounters Page Loop Segment Data Element Element Name Comments INTERCHANGE CONTROL HEADER App.C.4 ENVELOPE ISA 01 Authorization Information Qualifier Please use '00'. App.C.4 ENVELOPE ISA 03 Security Information Qualifier Please use '00'. State of Washington ProviderOne 5010 837 Encounter Companion Guide 27 WAMMIS-CG-837ENC-5010-01-12 App.C.4 ENVELOPE ISA 05 Interchange ID Qualifier Please use 'ZZ'. App.C.4 ENVELOPE ISA 06 Interchange Sender ID Please use the nine- digit alphanumeric submitter ID assigned during the enrollment process followed by spaces (e.g. 1234567AA). App.C.5 ENVELOPE ISA 07 Interchange ID Qualifier Please use 'ZZ'. App.C.5 ENVELOPE ISA 08 Interchange Receiver ID Please enter '77045' followed by spaces. App.C.5 ENVELOPE ISA 11 Repetition Separator Please use. App.C.6 ENVELOPE ISA 16 Component Element Separator Please use ':'. FUNCTIONAL GROUP HEADER App.C.7 ENVELOPE GS 02 Application Sender s Code Please use the nine- digit alphanumeric submitter ID assigned during the enrollment process. This should be the same as Loop 1000A, Data Element NM109 (e.g. 1234567AA). App.C.7 ENVELOPE GS 03 Application Receiver s Code Please use 77045. Beginning of Hierarchical Transaction 68 HEADER BHT 02 Transaction Set Purpose Code Please use 00 for Original. 69 HEADER BHT 06 Transaction Type Code Please use RP for encounters. Loop ID 1000A - Submitter Name State of Washington ProviderOne 5010 837 Encounter Companion Guide 28 WAMMIS-CG-837ENC-5010-01-12 72 1000A NM1 09 Identification Code Please use the nine- digit alphanumeric submitter ID assigned during the enrollment process (e.g. 1234567AA). Loop ID 1000B - Receiver Name 77 1000B NM1 03 Name Last or Organization Name Please use 'WA State HCA'. 77 1000B NM1 09 Identification Code Please use 77045. Billing Provider Specialty Information 80 2000A PRV NOTE: For medical and BH encounters this must always be the taxonomy for the provider who billed the MCO. Loop ID 2010AA - Billing Provider Name 85 2010AA NM1 NOTE: For medical and BH encounters this must always be the provider who billed the MCO. Subscriber Information 110 2000B SBR 03 Group or Policy number SBR03 is not used for medical or BH encounters submitted by MCOs. For encounters submitted by ASOs, the ASO unique consumer ID MUST be entered (even if already entered in 2010BA NM109). 110 2000B SBR 09 Claim Filing Indicator Code Please use 'MC'. Loop ID 2010BA - Subscriber Name State of Washington ProviderOne 5010 837 Encounter Companion Guide 29 WAMMIS-CG-837ENC-5010-01-12 114 2010BA NM1 09 Identification code For medical and BH encounters submitted by MCOs for Medicaid clients, please enter the ProviderOne Client ID. This ID is 11 digits in length and is alphanumeric in the following format: nine numeric digits followed by WA. Example: 123456789WA For encounters submitted by ASOs, one of the following MUST be entered: 1) The ProviderOne Client ID; or 2) The ASO unique consumer ID (i.e., this is the same information reported in Loop 2000B SBR03.) Subscriber Address 115 2010BA N3 NOTE: For homeless clients please enter unknown in N301. Subscriber City State Zip Code 116 2010BA N4 NOTE: For homeless clients please enter the city, state and zip code for the service provider. Subscriber Demographic Information State of Washington ProviderOne 5010 837 Encounter Companion Guide 30 WAMMIS-CG-837ENC-5010-01-12 118 2010BA DMG NOTE: HCA requires the DMG segment to be submitted as the patient is always the subscriber. Loop ID 2010BB - Payer Name 123 2010BB NM1 03 Last Name or Organization Name Please use 'WA State HCA. 123 2010BB NM1 09 Identification Code Please use '77045'. Billing Provider Secondary Identification 129 2010BB REF 01 Reference Identification Qualifier Please use G2. 130 2010BB REF 02 Reference Identification Please enter nine- digit, ProviderOne ID for the MCO or ASO here. Loop ID 2300 - Claim Information 145 2300 CLM 05-1 Facility Code Value MCO - Please enter appropriate place of service code. ASO Facility Code Value must be 11. Prior Authorization (Loop 2300) REF 01 Reference Identification Qualifier Please enter G1. REF 02 Reference Identification Please enter the nine- digit Evidence-Based Practice (EBP) code. Loop ID 2300 - Payer Claim Control Number 166 2300 REF 02 Reference Identification Please enter the 18 digit Transaction Control Number (TCN) of claim when CLM05-3 indicates the claim is a replacement or void. Diagnosis Related Group (DRG) Information State of Washington ProviderOne 5010 837 Encounter Companion Guide 31 WAMMIS-CG-837ENC-5010-01-12 218 2300 HI NOTE: Not used on ASO submitted encounters. Principle Procedure Information 240 2300 HI NOTE: Not used on ASO submitted encounters. Other Procedure Information 243 2300 HI NOTE: Not used on ASO submitted encounters. Other Procedure Information Value Information (Code) 284 2300 HI NOTE: Not used on ASO submitted encounters. Claim Pricing Repricing Information 314 2300 HCP NOTE: Not used on ASO submitted encounters. 314 2300 HCP 01 Pricing Methodology Please enter based on how the MCO reimbursed the claim: 00 Claim denied by MCO; or 02 MCO paid a non-capitated amount; or 07 MCO paid based on a capitation arrangement. 314 2300 HCP 02 Monetary Amount MCOs to report the Amount Paid (amount that MCO paid) to the Billing Pay-to provider or 0.00 if MCO denied the claim. State of Washington ProviderOne 5010 837 Encounter Companion Guide 32 WAMMIS-CG-837ENC-5010-01-12 314 2300 HCP 03 Monetary Amount MCO Allowed Amount (Usual and Customary) 316 2300 HCP 11 Unit or Basis For Measurement Code MCOs to use appropriate unit qualifier per IG. 316 2300 HCP 12 Quantity MCOs to report number of paid units. Attending Provider Name 319 2310A NM1 NOTE: For ASO submitted institutional encounters the attending provider will always be the E T Center, based on the decision not to report below the E T Center level. Loop ID 2310D - Rendering Provider Name 336 2310D NM1 Rendering Provider Name Enter the provider rendering service and NPI for Electronic Visit Verification (EVV) on Home Health Services claims. If different rendering provider for each service line, submit in 2420C for each service line. Service Facility Location Secondary Identification (2310E) 342 2310E NM1 Enter Clients service location in the example format below, for Electronic Visit Verification (EVV) on Home Health State of Washington ProviderOne 5010 837 Encounter Companion Guide 33 WAMMIS-CG-837ENC-5010-01-12 Services encounter claims. Example: NM1 77 2 Clients Location (Home or otherwise) NOTE: Submitting this segment triggers the requirement for N3 and N4 in the same loop. 347 2310E REF 01 Reference Identification Qualifier Please enter G2. 348 2310E REF 02 Reference Identification Please enter the site-specific, Department of Health (DOH) License Number. Provide just the certification number and do not include preceding characters (i.e., BHA.FS.60872639). DO NOT use the DSHS-DBHR Legacy License Number. Other Subscriber Information (Loop 2320) 356 2320 SBR 09 Claim Filing Indicator Code Use MA when submitting Medicare; otherwise use MC. Institutional Service Line (Loop 2400) 424 2400 SV2 01 Product Service ID MCO Please enter the revenue code for inpatient encounters using NUBC as code source. ASO Must always use revenue code 0124. State of Washington ProviderOne 5010 837 Encounter Companion Guide 34 WAMMIS-CG-837ENC-5010-01-12 425 2400 SV2 02 Service Line Procedure Code MCO Please refer to the IG. For outpatient encounters when HCPCS CPT code exists at line level. ASO Not used. 425 2400 SV2 SV202-1 Product Service ID Qualifier MCO Required if outpatient encounter and HCPCS CPT code exists at line level. ASO Not used. 426 2400 SV2 SV202-2 Product Service ID MCO Please enter the primary procedure code. This is required for outpatient encounters and must be submitted with HCPCS CPT procedure code (not ICD9 ICD10 procedure code). ASO Not used. 426 2400 SV2 SV202-3 Procedure Modifier MCO Please enter the procedure code modifier. This is required for outpatient encounters and if it clarifies the procedure. ASO Not used. State of Washington ProviderOne 5010 837 Encounter Companion Guide 35 WAMMIS-CG-837ENC-5010-01-12 427 2400 SV2 SV202-7 Time the service begins and ends. Enter service begin and end times in HHMM-HHMM format for Electronic Visit Verification (EVV) on Home Health Services encounter claims. Date - Service Date (Loop 2400) 434 2400 DTP NOTE: Not used for ASO submitted encounters. Line Pricing Re-pricing Information (Loop 2400) 443 2400 HCP NOTE: Used only for medical and BH encounters submitted by MCOs when appropriate. Not used for ASO submitted encounters. 443 2400 HCP 01 Pricing Methodology Please enter based on how the MCO reimbursed the claim: 00 Claim denied by MCO; or 02 MCO paid a non-capitated amount; or 07 MCO paid based on a capitation arrangement. 443 2400 HCP 02 Monetary Amount MCOs to report the Amount Paid (amount that MCO paid) to the Billing Pay-to provider or 0.00 if MCO denied the claim. State of Washington ProviderOne 5010 837 Encounter Companion Guide 36 WAMMIS-CG-837ENC-5010-01-12 443 2400 HCP 03 Monetary Amount MCO Allowed Amount (Usual and Customary) 447 2400 HCP 11 Unit or Basis For Measurement Code MCOs to use appropriate unit qualifier per IG. 447 2400 HCP 12 Quantity MCOs to report number of paid units. LIN Drug Information (Loop 2410) 450 2410 LIN NOTE: Not used for ASO submitted encounters. CTP Drug Quantity 452 2410 CTP NOTE: Not used for ASO submitted encounters. Loop ID 2420C - Rendering Provider Name 336 2420C NM1 Rendering Provider Name Enter the provider rendering service and NPI for Electronic Visit Verification (EVV) on Home Health Services claims. | /kaggle/input/edi-db-835-837/837-Encounters-CG.pdf | 4362743e4e6fd23da15bccd26a737619 | 4362743e4e6fd23da15bccd26a737619_0 |
Stedi maintains this guide based on public documentation from Texas Medicaid Healthcare Partnerships (TMHP). Contact Texas Medicaid Healthcare Partnerships (TMHP) for official EDI specifications. To report any errors in this guide, please contact us. X12 837 837 Health Care Claim: Professional (X222 A2 A1) X12 Release 5010 Revised January 18, 2024 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care 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 billing information, 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 to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and or payment of health care services within a specific health care insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such 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 a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care insurance industry segment. Delimiters Segment Element Component Repetition View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view tmhp 837-health-care-claim-professional- x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 POWERED BY Build EDI implementation guides at stedi.com 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 1 552 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0050 Transaction Set Header Max use 1 Required BHT 0100 Beginning of Hierarchical Transaction Max use 1 Required Submitter Name Loop NM1 0200 Submitter Name Max use 1 Required PER 0450 Submitter EDI Contact Information Max use 2 Required Receiver Name Loop NM1 0200 Receiver Name Max use 1 Required Detail Billing Provider Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PRV 0030 Billing Provider Specialty Information Max use 1 Optional CUR 0100 Foreign Currency Information Max use 1 Optional Billing Provider Name Loop NM1 0150 Billing Provider Name Max use 1 Required N3 0250 Billing Provider Address Max use 1 Required N4 0300 Billing Provider City, State, ZIP Code Max use 1 Required REF 0350 Billing Provider Tax Identification Max use 1 Required REF 0350 Billing Provider UPIN License Information Max use 2 Optional PER 0400 Billing Provider Contact Information Max use 2 Optional Pay-to Address Name Loop NM1 0150 Pay-to Address Name Max use 1 Required N3 0250 Pay-to Address - ADDRESS Max use 1 Required N4 0300 Pay-To Address City, State, ZIP Code Max use 1 Required Pay-To Plan Name Loop NM1 0150 Pay-To Plan Name Max use 1 Required N3 0250 Pay-to Plan Address Max use 1 Required N4 0300 Pay-To Plan City, State, ZIP Code Max use 1 Required REF 0350 Pay-to Plan Secondary Identification Max use 1 Optional REF 0350 Pay-To Plan Tax Identification Number Max use 1 Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 2 552 2300 Loop CLM 1300 Health Claim Max use 1 Required REF 1800 Referral Number Max use 30 Optional NTE 1900 Claim Note Max use 20 Optional HI 2310 Health Care Information Codes Max use 25 Optional Subscriber Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required SBR 0050 Subscriber Information Max use 1 Required PAT 0070 Patient Information Max use 1 Optional Subscriber Name Loop NM1 0150 Subscriber Name Max use 1 Required N3 0250 Subscriber Address Max use 1 Optional N4 0300 Subscriber City, State, ZIP Code Max use 1 Optional DMG 0320 Subscriber Demographic Information Max use 1 Optional REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Subscriber Secondary Identification Max use 1 Optional PER 0400 Property and Casualty Subscriber Contact Information Max use 1 Optional Payer Name Loop NM1 0150 Payer Name Max use 1 Required N3 0250 Payer Address Max use 1 Optional N4 0300 Payer City, State, ZIP Code Max use 1 Optional REF 0350 Billing Provider Secondary Identification Max use 2 Optional REF 0350 Payer Secondary Identification Max use 3 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Date - Accident Max use 1 Optional DTP 1350 Date - Acute Manifestation Max use 1 Optional DTP 1350 Date - Admission Max use 1 Optional DTP 1350 Date - Assumed and Relinquished Care Dates Max use 2 Optional DTP 1350 Date - Authorized Return to Work Max use 1 Optional DTP 1350 Date - Disability Dates Max use 1 Optional DTP 1350 Date - Discharge Max use 1 Optional DTP 1350 Date - Hearing and Vision Prescription Date Max use 1 Optional DTP 1350 Date - Initial Treatment Date Max use 1 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 3 552 DTP 1350 Date - Last Menstrual Period Max use 1 Optional DTP 1350 Date - Last Seen Date Max use 1 Optional DTP 1350 Date - Last Worked Max use 1 Optional DTP 1350 Date - Last X-ray Date Max use 1 Optional DTP 1350 Date - Onset of Current Illness or Symptom Max use 1 Optional DTP 1350 Date - Property and Casualty Date of First Contact Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Amount Paid Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Care Plan Oversight Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Mammography Certification Number Max use 1 Optional REF 1800 Mandatory Medicare (Section 4081) Crossover Indicator Max use 1 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Claim Note Max use 1 Optional CR1 1950 Ambulance Transport Information Max use 1 Optional CR2 2000 Spinal Manipulation Service Information Max use 1 Optional CRC 2200 Ambulance Certification Max use 3 Optional CRC 2200 EPSDT Referral Max use 1 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 Patient Condition Information: Vision Max use 3 Optional HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 4 552 HI 2310 Health Care Diagnosis Code Max use 1 Required HCP 2410 Claim Pricing Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required PRV 2550 Rendering Provider Specialty Information Max use 1 Optional REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional PER 2750 Service Facility Contact Information Max use 1 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 Optional Ambulance Pick-up Location Loop NM1 2500 Ambulance Pick-up Location Max use 1 Required N3 2650 Ambulance Pick-up Location Address Max use 1 Required N4 2700 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 2500 Ambulance Drop-off Location Max use 1 Required N3 2650 Ambulance Drop-off Location Address Max use 1 Required N4 2700 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 5 552 OI 3100 Other Insurance Coverage Information Max use 1 Required MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 1 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3450 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Rendering Provider Loop NM1 3250 Other Payer Rendering Provider Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 3 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Supervising Provider Loop NM1 3250 Other Payer Supervising Provider Max use 1 Required REF 3550 Other Payer Supervising Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 6 552 Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV1 3700 Professional Service Max use 1 Required SV5 4000 Durable Medical Equipment Service Max use 1 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 Optional PWK 4200 Line Supplemental Information Max use 10 Optional CR1 4250 Ambulance Transport Information Max use 1 Optional CR3 4350 Durable Medical Equipment Certification Max use 1 Optional CRC 4500 Ambulance Certification Max use 3 Optional CRC 4500 Condition Indicator Durable Medical Equipment Max use 1 Optional CRC 4500 Hospice Employee Indicator Max use 1 Optional DTP 4550 Date - Begin Therapy Date Max use 1 Optional DTP 4550 DATE - Certification Revision Recertification Date Max use 1 Optional DTP 4550 Date - Initial Treatment Date Max use 1 Optional DTP 4550 Date - Last Certification Date Max use 1 Optional DTP 4550 Date - Last Seen Date Max use 1 Optional DTP 4550 Date - Last X-ray Date Max use 1 Optional DTP 4550 Date - Prescription Date Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Required DTP 4550 Date - Shipped Date Max use 1 Optional DTP 4550 Date - Test Date Max use 2 Optional QTY 4600 Ambulance Patient Count Max use 1 Optional QTY 4600 Obstetric Anesthesia Additional Units Max use 1 Optional MEA 4620 Test Result Max use 5 Optional CN1 4650 Contract Information Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 4700 Immunization Batch Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Mammography Certification Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional REF 4700 Referral Number Max use 5 Optional REF 4700 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 7 552 REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Postage Claimed Amount Max use 1 Optional AMT 4750 Sales Tax Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional NTE 4850 Line Note Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional PS1 4880 Purchased Service Information Max use 1 Optional HCP 4920 Line Pricing Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required PRV 5050 Rendering Provider Specialty Information Max use 1 Optional REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Purchased Service Provider Name Loop NM1 5000 Purchased Service Provider Name Max use 1 Required REF 5250 Purchased Service Provider Secondary Identification Max use 20 Optional Service Facility Location Name Loop NM1 5000 Service Facility Location Name Max use 1 Required N3 5140 Service Facility Location Address Max use 1 Required N4 5200 Service Facility Location City, State, ZIP Code Max use 1 Required REF 5250 Service Facility Location Secondary Identification Max use 3 Optional Supervising Provider Name Loop NM1 5000 Supervising Provider Name Max use 1 Required REF 5250 Supervising Provider Secondary Identification Max use 20 Optional Ordering Provider Name Loop NM1 5000 Ordering Provider Name Max use 1 Required N3 5140 Ordering Provider Address Max use 1 Optional N4 5200 Ordering Provider City, State, ZIP Code Max use 1 Optional REF 5250 Ordering Provider Secondary Identification Max use 20 Optional PER 5300 Ordering Provider Contact Information Max use 1 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 8 552 Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Ambulance Pick-up Location Loop NM1 5000 Ambulance Pick-up Location Max use 1 Required N3 5140 Ambulance Pick-up Location Address Max use 1 Required N4 5200 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 5000 Ambulance Drop-off Location Max use 1 Required N3 5140 Ambulance Drop-off Location Address Max use 1 Required N4 5200 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional Form Identification Code Loop LQ 5510 Form Identification Code Max use 1 Required FRM 5520 Supporting Documentation Max use 99 Required Patient Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PAT 0070 Patient Information Max use 1 Required Patient Name Loop NM1 0150 Patient Name Max use 1 Required N3 0250 Patient Address Max use 1 Required N4 0300 Patient City, State, ZIP Code Max use 1 Required DMG 0320 Patient Demographic Information Max use 1 Required REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Property and Casualty Patient Identifier Max use 1 Optional PER 0400 Property and Casualty Patient Contact Information Max use 1 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Date - Accident Max use 1 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 9 552 DTP 1350 Date - Acute Manifestation Max use 1 Optional DTP 1350 Date - Admission Max use 1 Optional DTP 1350 Date - Assumed and Relinquished Care Dates Max use 2 Optional DTP 1350 Date - Authorized Return to Work Max use 1 Optional DTP 1350 Date - Disability Dates Max use 1 Optional DTP 1350 Date - Discharge Max use 1 Optional DTP 1350 Date - Hearing and Vision Prescription Date Max use 1 Optional DTP 1350 Date - Initial Treatment Date Max use 1 Optional DTP 1350 Date - Last Menstrual Period Max use 1 Optional DTP 1350 Date - Last Seen Date Max use 1 Optional DTP 1350 Date - Last Worked Max use 1 Optional DTP 1350 Date - Last X-ray Date Max use 1 Optional DTP 1350 Date - Onset of Current Illness or Symptom Max use 1 Optional DTP 1350 Date - Property and Casualty Date of First Contact Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Amount Paid Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Care Plan Oversight Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Mammography Certification Number Max use 1 Optional REF 1800 Mandatory Medicare (Section 4081) Crossover Indicator Max use 1 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Claim Note Max use 1 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 10 552 CR1 1950 Ambulance Transport Information Max use 1 Optional CR2 2000 Spinal Manipulation Service Information Max use 1 Optional CRC 2200 Ambulance Certification Max use 3 Optional CRC 2200 EPSDT Referral Max use 1 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 Patient Condition Information: Vision Max use 3 Optional HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Health Care Diagnosis Code Max use 1 Required HCP 2410 Claim Pricing Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required PRV 2550 Rendering Provider Specialty Information Max use 1 Optional REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional PER 2750 Service Facility Contact Information Max use 1 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 Optional Ambulance Pick-up Location Loop NM1 2500 Ambulance Pick-up Location Max use 1 Required N3 2650 Ambulance Pick-up Location Address Max use 1 Required N4 2700 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 2500 Ambulance Drop-off Location Max use 1 Required N3 2650 Ambulance Drop-off Location Address Max use 1 Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 11 552 N4 2700 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 1 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3450 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Rendering Provider Loop NM1 3250 Other Payer Rendering Provider Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 3 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 12 552 REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Supervising Provider Loop NM1 3250 Other Payer Supervising Provider Max use 1 Required REF 3550 Other Payer Supervising Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV1 3700 Professional Service Max use 1 Required SV5 4000 Durable Medical Equipment Service Max use 1 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 Optional PWK 4200 Line Supplemental Information Max use 10 Optional CR1 4250 Ambulance Transport Information Max use 1 Optional CR3 4350 Durable Medical Equipment Certification Max use 1 Optional CRC 4500 Ambulance Certification Max use 3 Optional CRC 4500 Condition Indicator Durable Medical Equipment Max use 1 Optional CRC 4500 Hospice Employee Indicator Max use 1 Optional DTP 4550 Date - Begin Therapy Date Max use 1 Optional DTP 4550 DATE - Certification Revision Recertification Date Max use 1 Optional DTP 4550 Date - Initial Treatment Date Max use 1 Optional DTP 4550 Date - Last Certification Date Max use 1 Optional DTP 4550 Date - Last Seen Date Max use 1 Optional DTP 4550 Date - Last X-ray Date Max use 1 Optional DTP 4550 Date - Prescription Date Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Required DTP 4550 Date - Shipped Date Max use 1 Optional DTP 4550 Date - Test Date Max use 2 Optional QTY 4600 Ambulance Patient Count Max use 1 Optional QTY 4600 Obstetric Anesthesia Additional Units Max use 1 Optional MEA 4620 Test Result Max use 5 Optional CN1 4650 Contract Information Max use 1 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 13 552 REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 4700 Immunization Batch Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Mammography Certification Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional REF 4700 Referral Number Max use 5 Optional REF 4700 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Postage Claimed Amount Max use 1 Optional AMT 4750 Sales Tax Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional NTE 4850 Line Note Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional PS1 4880 Purchased Service Information Max use 1 Optional HCP 4920 Line Pricing Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required PRV 5050 Rendering Provider Specialty Information Max use 1 Optional REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Purchased Service Provider Name Loop NM1 5000 Purchased Service Provider Name Max use 1 Required REF 5250 Purchased Service Provider Secondary Identification Max use 20 Optional Service Facility Location Name Loop NM1 5000 Service Facility Location Name Max use 1 Required N3 5140 Service Facility Location Address Max use 1 Required N4 5200 Service Facility Location City, State, ZIP Code Max use 1 Required REF 5250 Service Facility Location Secondary Identification Max use 3 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 14 552 Supervising Provider Name Loop NM1 5000 Supervising Provider Name Max use 1 Required REF 5250 Supervising Provider Secondary Identification Max use 20 Optional Ordering Provider Name Loop NM1 5000 Ordering Provider Name Max use 1 Required N3 5140 Ordering Provider Address Max use 1 Optional N4 5200 Ordering Provider City, State, ZIP Code Max use 1 Optional REF 5250 Ordering Provider Secondary Identification Max use 20 Optional PER 5300 Ordering Provider Contact Information Max use 1 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Ambulance Pick-up Location Loop NM1 5000 Ambulance Pick-up Location Max use 1 Required N3 5140 Ambulance Pick-up Location Address Max use 1 Required N4 5200 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 5000 Ambulance Drop-off Location Max use 1 Required N3 5140 Ambulance Drop-off Location Address Max use 1 Required N4 5200 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional Form Identification Code Loop LQ 5510 Form Identification Code Max use 1 Required FRM 5520 Supporting Documentation Max use 99 Required SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 15 552 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250130 2312 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 16 552 Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 17 552 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HC XX XXXXX 20250131 0137 000000000 XX 005010X 222A2 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HC Health Care Claim (837) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 18 552 005010X222A2 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 19 552 Heading ST 0050 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 837 0001 005010X222A2 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). 837 Health Care Claim ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. ST-03 1705 Implementation Guide Version Name String (AN) Required Reference assigned to identify Implementation Convention The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08. Usage notes This element must be populated with the guide identifier named in Section 1.2. This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time. 005010X222A2 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 20 552 BHT 0100 Heading BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT 0019 18 XXX 20250131 0810 RP Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. 18 Reissue If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent. BHT-03 127 Originator Application Transaction Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 21 552 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim or Encounter Identifier Identifier (ID) Required Code specifying the type of transaction 31 Subrogation Demand The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners. NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction. CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. RP Reporting Use RP when the entire ST-SE envelope contains only capitated encounters. Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 22 552 1000A Submitter Name Loop Max 1 Required Variants (all may be used) Receiver Name Loop NM1 0200 Heading Submitter Name Loop NM1 Submitter Name To supply the full name of an individual or organizational entity Usage notes The submitter is the entity responsible for the creation and formatting of this transaction. Example NM1 41 1 XXXXXX X XXXX 46 XXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 41 Submitter NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Submitter Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Submitter First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Submitter Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) Established by trading partner agreement NM1-09 67 Submitter Identifier Min 2 Max 80 String (AN) Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 23 552 Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 24 552 PER 0450 Heading Submitter Name Loop PER Submitter EDI Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER IC XXXX FX XXXX FX XX FX XXXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Submitter Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 25 552 1000A Submitter Name Loop end EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 26 552 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop 1000B Receiver Name Loop end Heading end NM1 0200 Heading Receiver Name Loop NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1 40 2 TMHP 46 617591011CMSP Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 40 Receiver NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Receiver Name String (AN) Required Individual last name or organizational name TMHP NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier String (AN) Required Code identifying a party or other code 617591011CMSP 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 27 552 Detail 2000A Billing Provider Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 1 20 1 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_0 |
364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 26 552 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop 1000B Receiver Name Loop end Heading end NM1 0200 Heading Receiver Name Loop NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1 40 2 TMHP 46 617591011CMSP Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 40 Receiver NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Receiver Name String (AN) Required Individual last name or organizational name TMHP NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier String (AN) Required Code identifying a party or other code 617591011CMSP 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 27 552 Detail 2000A Billing Provider Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 1 20 1 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 28 552 PRV 0030 Detail Billing Provider Hierarchical Level Loop PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRV BI PXC XX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The Taxonomy code must be the Taxonomy code on file with Texas Medicaid. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 29 552 CUR 0100 Detail Billing Provider Hierarchical Level Loop CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send. It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars. Example CUR 85 XXX Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD Canadian dollars would be valid, while CA Canada would be invalid. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 30 552 2010AA Billing Provider Name Loop Max 1 Required Variants (all may be used) Pay-to Address Name Loop Pay-To Plan Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop NM1 Billing Provider Name To supply the full name of an individual or organizational entity Usage notes Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID- 2010BB. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop. The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration). When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. Example NM1 85 2 XXX XXXXXX XXXXX X XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Billing Provider Last or Organizational Name Min 1 Max 60 String (AN) Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 31 552 Individual last name or organizational name NM1-04 1036 Billing Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Billing Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Billing Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Billing Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes National Provider ID (NPI) must be submitted unless the provider has an Atypical Provider Identifier (API) assigned which will be reported in Loop 2010BB. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 32 552 N3 0250 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N3 Billing Provider Address To specify the location of the named party Usage notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3 XXX XXX Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information Usage notes The Billing Provider address must be the address on file with Texas Medicaid. N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 33 552 N4 0300 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXXX XX XXXXXXX XXX Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Billing Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Usage notes The Billing Provider city name must be the city name on file with Texas Medicaid. N4-02 156 Billing Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Billing Provider Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes The Billing Provider ZIP Code (9 digits) name must be the ZIP Code on file with Texas Medicaid. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 34 552 REF 0350 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop REF Billing Provider Tax Identification To specify identifying information Usage notes The submitted code must match what is on file with Texas Medicaid Example REF SY X Variants (all may be used) REF Billing Provider UPIN License Information Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Billing Provider Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 35 552 REF 0350 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop REF Billing Provider UPIN License Information To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and or license number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification. Example REF 0B XXXXX Variants (all may be used) REF Billing Provider Tax Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. REF-02 127 Billing Provider License and or UPIN Information Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 36 552 PER 0400 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.; When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER IC X TE XXX FX XXXXXX TE XX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Billing Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 37 552 2010AA Billing Provider Name Loop end PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 38 552 2010AB Pay-to Address Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-To Plan Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information. Example NM1 87 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 87 Pay-to Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 39 552 N3 0250 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop N3 Pay-to Address - ADDRESS To specify the location of the named party Example N3 XXXXXX X Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 40 552 2010AB Pay-to Address Name Loop end N4 0300 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop N4 Pay-To Address City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXXX XX XXXXXXX XX Only one of Pay-to Address State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-to Address City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-to Address State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-to Address Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 41 552 2010AC Pay-To Plan Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-to Address Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop NM1 Pay-To Plan Name To supply the full name of an individual or organizational entity Usage notes Required when willing trading partners agree to use this implementation for their subrogation payment requests. This loop may only be used when BHT06 31. Example NM1 PE 2 XX XV XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee PE is used to indicate the subrogated payee. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Pay-To Plan Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 42 552 NM1-09 67 Pay-To Plan Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 43 552 N3 0250 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop N3 Pay-to Plan Address To specify the location of the named party Example N3 XXXXXX XXXXXX Max use 1 Required N3-01 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 44 552 N4 0300 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop N4 Pay-To Plan City, State, ZIP Code To specify the geographic place of the named party Example N4 XX XX XXXXXXX XXX Only one of Pay-To Plan State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-To Plan City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-To Plan State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-To Plan Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 45 552 REF 0350 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop REF Pay-to Plan Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF NF XXXXX Variants (all may be used) REF Pay-To Plan Tax Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Pay-to Plan Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 46 552 2010AC Pay-To Plan Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Pay-To Plan Name Loop REF Pay-To Plan Tax Identification Number To specify identifying information Example REF EI XX Variants (all may be used) REF Pay-to Plan Secondary Identification Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Pay-To Plan Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 47 552 2300 Loop Max 1 Optional CLM 1300 Detail Billing Provider Hierarchical Level Loop 2300 Loop CLM Health Claim To specify basic data about the claim Example CLM XXXX Max use 1 Required CLM-01 1028 Claim Submitter's Identifier Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 48 552 REF 1800 Detail Billing Provider Hierarchical Level Loop 2300 Loop REF Referral Number To specify identifying information Example REF XXX XXXXXXXX Max use 30 Optional REF-01 128 Reference Identification Qualifier Min 2 Max 3 Identifier (ID) Required Code qualifying the Reference Identification REF-02 127 Referral Number Min 8 Max 8 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes REF02 must contain a valid referral number when applicable. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 49 552 NTE 1900 Detail Billing Provider Hierarchical Level Loop 2300 Loop NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Example NTE ADD XXX Max use 20 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information NTE-02 352 Description Min 1 Max 5 String (AN) Required A free-form description to clarify the related data elements and their content Usage notes To submit Billing Provider Service Group, enter the appropriate Service Group code for Billing Provider. NTE01 ADD NTE02 Positions 24-28 (left justified) (Refer to Long Term Care Reference Codes, under the LTC and Acute Care Reference Codes dropdown, on the TMHP.com website https: www.tmhp.com topics edi) 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 50 552 2300 Loop end HI 2310 Detail Billing Provider Hierarchical Level Loop 2300 Loop HI Health Care Information Codes To supply information related to the delivery of health care Usage notes Texas Medicaid will only capture the first 4 diagnosis codes (HI01 to HI04) for processing the file. Example HI Max use 25 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 51 552 2000B Subscriber Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 2 1 22 1 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 22 Subscriber HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 0 No Subordinate HL Segment in This Hierarchical Structure. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 52 552 SBR 0050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBR C 18 XXXXXX XXXXX 16 14 Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. 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 This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 53 552 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 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) Medicare Risk 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 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 54 552 PAT 0070 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop PAT Patient Information To supply patient information Usage notes Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met. If not required by this implementation guide, do not send. Example PAT D8 XXXX 01 00 Y If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required Max use 1 Optional PAT-05 1250 Date Time Period Format Qualifier Identifier (ID) Optional Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD PAT-06 1251 Patient Death Date Min 1 Max 35 String (AN) Optional Expression of a date, a time, or range of dates, times or dates and times PAT06 is the date of death. PAT-07 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken 01 Actual Pounds PAT-08 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight PAT08 is the patient's weight. PAT-09 1073 Pregnancy Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 55 552 2010BA Subscriber Name Loop Max 1 Required Variants (all may be used) Payer Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes 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. Example NM1 IL 1 XXXXX XXXXXX XX XX MI XXX If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 56 552 Code designating the system method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 57 552 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3 XXXXX XXXX Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Subscriber Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 58 552 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop N4 Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4 XXXXXXX XX XXXXXXX XXX Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Subscriber State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 59 552 DMG 0320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop DMG Subscriber Demographic Information To supply demographic information Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example DMG D8 XX U Max use 1 Optional DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Subscriber Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Subscriber Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 60 552 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop REF Property and Casualty Claim Number To specify identifying information Usage notes Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Example REF Y4 X Variants (all may be used) REF Subscriber Secondary Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 61 552 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop REF Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY XX Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Subscriber Supplemental Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 62 552 PER 0400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop PER Property and Casualty Subscriber Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC XX TE XXXX EX X If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 63 552 2010BA Subscriber Name Loop end 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 64 552 2010BB Payer Name Loop Max 1 Required Variants (all | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_1 |
Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Subscriber Supplemental Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 62 552 PER 0400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop PER Property and Casualty Subscriber Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC XX TE XXXX EX X If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 63 552 2010BA Subscriber Name Loop end 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 64 552 2010BB Payer Name Loop Max 1 Required Variants (all may be used) Subscriber Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop NM1 Payer Name To supply the full name of an individual or organizational entity Usage notes This is the destination payer. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator. Example NM1 PR 2 TDMHMR PI 617591011CMSP Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Payer Name String (AN) Required Individual last name or organizational name TDHS TDHS TDMHMR TDMHMR NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 65 552 NM1-09 67 Payer Identifier String (AN) Required Code identifying a party or other code 617591011CMSP 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 66 552 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N3 Payer Address To specify the location of the named party Usage notes 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. Example N3 X XXX Max use 1 Optional N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 67 552 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XXXXX XX XXXXXXX XXX Only one of Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 68 552 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop REF Billing Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF G2 XXXX Variants (all may be used) REF Payer Secondary Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes If the provider has an API instead of an NPI, the API must be sent in the REF02. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Billing Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 69 552 2010BB Payer Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop REF Payer Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF EI XXXXX Variants (all may be used) REF Billing Provider Secondary Identification Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 70 552 2300 Claim Information Loop Max 100 Optional CLM 1300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. 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 hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLM XXXX 0 X B X N C Y I P OA XXX XX XX 03 1 Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is 20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 71 552 CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Place of Service Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. B Place of Service Codes for Professional or Dental Services C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-06 1073 Provider or Supplier Signature Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file. N No Y Yes CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 72 552 Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-10 1351 Patient Signature Source Code Identifier (ID) Optional Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. CLM-11 C024 Related Causes Information To identify one or more related causes and associated state or country information Usage notes Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send. Max use 1 Optional C024-01 1362 Related Causes Code Identifier (ID) Required Code identifying an accompanying cause of an illness, injury or an accident AA Auto Accident EM Employment OA Other Accident C024-02 1362 Related Causes Code Min 2 Max 3 Identifier (ID) Optional Code identifying an accompanying cause of an illness, injury or an accident C024-04 156 Auto Accident State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA". 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 73 552 C024-05 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country CLM-12 1366 Special Program Indicator Identifier (ID) Optional Code indicating the Special Program under which the services rendered to the patient were performed 02 Physically Handicapped Children's Program This code is used for Medicaid claims only. 03 Special Federal Funding This code is used for Medicaid claims only. 05 Disability This code is used for Medicaid claims only. 09 Second Opinion or Surgery This code is used for Medicaid claims only. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 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 Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 74 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Accident To specify any or all of a date, a time, or a time period Usage notes Required when CLM11-1 or CLM11-2 has a value of AA' or OA'. OR Required when CLM11-1 or CLM11-2 has a value of EM' and this claim is the result of an accident. If not required by this implementation guide, do not send. Example DTP 439 D8 XXXXXX Variants (all may be used) DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 439 Accident DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Accident Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 75 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Acute Manifestation To specify any or all of a date, a time, or a time period Usage notes Required when Loop ID-2300 CR208 "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send. Example DTP 453 D8 X Variants (all may be used) DTP Date - Accident DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 453 Acute Manifestation of a Chronic Condition DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Acute Manifestation Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 76 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Admission To specify any or all of a date, a time, or a time period Usage notes Required on all ambulance claims when the patient was known to be admitted to the hospital. OR Required on all claims involving inpatient medical visits. If not required by this implementation guide, do not send. Example DTP 435 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Admission Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 77 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Assumed and Relinquished Care Dates To specify any or all of a date, a time, or a time period Usage notes Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send. Assumed Care Date is the date care was assumed by another provider during post- operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A". Example DTP 090 D8 XX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 090 Report Start Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care. 091 Report End Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Assumed or Relinquished Care Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 78 552 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 79 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Authorized Return to Work To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP 296 D8 XXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 296 Initial Disability Period Return To Work This is the date the provider has authorized the patient to return to work. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Work Return Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 80 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Disability Dates To specify any or all of a date, a time, or a time period Usage notes Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his her work. OR Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor. If not required by this implementation guide, do not send. Example DTP 314 D8 XXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 314 Disability Use code 314 when both disability start and end date are being reported. 360 Initial Disability Period Start Use code 360 if patient is currently disabled and disability end date is unknown. 361 Initial Disability Period End Use code 361 if patient is no longer disabled and the start date is unknown. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD Use code D8 when DTP01 is 360 or 361. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use code RD8 when DTP01 is 314. DTP-03 1251 Disability From Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 81 552 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 82 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Discharge To specify any or all of a date, a time, or a time period Usage notes Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send. Example DTP 096 D8 XXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Discharge Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 83 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Hearing and Vision Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send. Example DTP 471 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 84 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 454 D8 XXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 85 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Last Menstrual Period To specify any or all of a date, a time, or a time period Usage notes Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send. Example DTP 484 D8 XX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 484 Last Menstrual Period DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Menstrual Period Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 86 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 304 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Seen Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 87 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Last Worked To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP 297 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 297 Initial Disability Period Last Day Worked DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Worked Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 88 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 455 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 89 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Onset of Current Illness or Symptom To specify any or all of a date, a time, or a time period Usage notes Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send. This date is the onset of acute symptoms for the current illness or condition. Example DTP 431 D8 X Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 431 Onset of Current Symptoms or Illness DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Onset of Current Illness or Injury Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 90 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Property and Casualty Date of First Contact To specify any or all of a date, a time, or a time period Usage notes Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send. This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_2 |
Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 89 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Onset of Current Illness or Symptom To specify any or all of a date, a time, or a time period Usage notes Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send. This date is the onset of acute symptoms for the current illness or condition. Example DTP 431 D8 X Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 431 Onset of Current Symptoms or Illness DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Onset of Current Illness or Injury Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 90 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Property and Casualty Date of First Contact To specify any or all of a date, a time, or a time period Usage notes Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send. This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date. Example DTP 444 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 444 First Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Date Time Period Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 91 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP 050 D8 X Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 92 552 PWK 1550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK 11 BM AC XXXXXXX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 93 552 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 94 552 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 95 552 CN1 1600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet 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. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN1 05 000000000000000 000000 X 000 X Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 96 552 CN106 is an additional identifying number for the contract. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 97 552 AMT 1750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop AMT Patient Amount Paid To indicate the total monetary amount Usage notes Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s). Example AMT F5 0 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F5 Patient Amount Paid AMT-02 782 Patient Amount Paid Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 98 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF 9C XXXXX Variants (all may be used) REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 99 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Care Plan Oversight To specify identifying information Usage notes Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send. This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished. Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number. On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI. Example REF 1J XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1J Facility ID Number REF-02 127 Care Plan Oversight Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 100 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REF D9 XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 101 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line. In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400. Example REF X4 XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 102 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF P4 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 103 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REF LX XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 104 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send. Example REF EW XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 105 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Mandatory Medicare (Section 4081) Crossover Indicator To specify identifying information Usage notes Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send. Example REF F5 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F5 Medicare Version Code REF-02 127 Medicare Section 4081 Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The allowed values for this element are: Y 4081 N Regular crossover 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 106 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REF EA XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 107 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF F8 XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 108 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF G1 X Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 109 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF 9F X Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 110 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF 9A XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 111 552 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF 4N XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Allowable values for this element are: 1 Immediate Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 6 Request for Override Pending 7 Special Handling 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 112 552 K3 1850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop K3 File Information To transmit a fixed-format record or matrix contents Usage notes 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. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3 XXX Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 113 552 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTE CER X Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information CER Certification Narrative DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description TPO Third Party Organization Notes NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 114 552 CR1 1950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send. The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101. Example CR1 LB 0000 A DH 00 XXX XXXX If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both Can be used to indicate that the patient was transferred to a residential facility. B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CR106 is the distance traveled during transport. Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 115 552 CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 116 552 CR2 2000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CR2 Spinal Manipulation Service Information To supply information related to the chiropractic service rendered to a patient Usage notes Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. Example CR2 F XXX XX Max use 1 Optional CR2-08 1342 Patient Condition Code Identifier (ID) Required Code indicating the nature of a patient's condition A Acute Condition C Chronic Condition D Non-acute E Non-Life Threatening F Routine G Symptomatic M Acute Manifestation of a Chronic Condition CR2-10 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR210 is a description of the patient's condition. CR2-11 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR211 is an additional description of the patient's condition. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 117 552 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC Ambulance Certification To supply information on conditions Usage notes Required when the claim involves ambulance transport services AND when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send. The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01. Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07. Example CRC 07 Y 06 XXX XXX XXX XX Variants (all may be used) CRC EPSDT Referral CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 118 552 Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 119 552 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC EPSDT Referral To supply information on conditions Usage notes Required on Early Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRC ZZ N AV XX XX Variants (all may be used) CRC Ambulance Certification CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 120 552 corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 121 552 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC Homebound Indicator To supply information on conditions Usage notes Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send. Example CRC 75 Y IH Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 75 Functional Limitations CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Y Yes CRC-03 1321 Homebound Indicator Identifier (ID) Required Code indicating a condition IH Independent at Home 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 122 552 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC Patient Condition Information: Vision To supply information on conditions Usage notes Required on | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_3 |
do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 120 552 corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 121 552 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC Homebound Indicator To supply information on conditions Usage notes Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send. Example CRC 75 Y IH Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 75 Functional Limitations CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Y Yes CRC-03 1321 Homebound Indicator Identifier (ID) Required Code indicating a condition IH Independent at Home 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 122 552 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC Patient Condition Information: Vision To supply information on conditions Usage notes Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send. Example CRC E3 N L5 XXX XXX XXX XX Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Homebound Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. E1 Spectacle Lenses E2 Contact Lenses E3 Spectacle Frames CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition L1 General Standard of 20 Degree or.5 Diopter Sphere or Cylinder Change Met L2 Replacement Due to Loss or Theft L3 Replacement Due to Breakage or Damage L4 Replacement Due to Patient Preference L5 Replacement Due to Medical Reason CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 123 552 Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 124 552 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Anesthesia Related Procedure To supply information related to the delivery of health care Usage notes Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code. If not required by this implementation guide, do not send. Example HI BP XXXX BO X Variants (all may be used) HI Condition Information HI Health Care Diagnosis Code Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BP Health Care Financing Administration Common Procedural Coding System Principal Procedure C022-02 1271 Anesthesia Related Surgical Procedure Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BO Health Care Financing Administration Common Procedural Coding System C022-02 1271 Industry Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 125 552 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Condition Information To supply information related to the delivery of health care Usage notes Required when condition information applies to the claim. If not required by this implementation guide, do not send. Example HI BG XX BG X BG XXXXX BG XXX BG XXXXX BG XXXX B G XXXXX BG XX BG XXXXX BG XXXXXX BG XXXXXX BG XXX XXX Variants (all may be used) HI Anesthesia Related Procedure HI Health Care Diagnosis Code Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 126 552 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 127 552 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 128 552 BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 129 552 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 130 552 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Health Care Diagnosis Code To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BK XX ABF XXXXX ABF XXX BF XX ABF XXX ABF XXX X ABF XXXXXX BF XXXX BF X ABF XXXXXX ABF XXXXX AB F XXX Variants (all may be used) HI Anesthesia Related Procedure HI Condition Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 131 552 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 132 552 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 133 552 the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis ICD-9 Codes C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 134 552 the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 135 552 OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 136 552 OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 137 552 HCP 2410 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HCP Claim Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 11 00000000000 00000 XXXXXX 000 XXXXXX 000000 000000000 T3 4 6 Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 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 Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 138 552 Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Min 1 Max 9 Decimal number (R) Optional Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved Ambulatory Patient Group Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Ambulatory Patient Group Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 139 552 HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 140 552 2310A Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required when this claim involves a referral. If not required by this implementation guide, do not send. When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed reported in this transaction. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 DN 1 XXXXXX XXXXXX XXX X XX XX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 141 552 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 142 552 2310A Referring Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 1G XXXXX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 143 552 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, do not send. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 82 1 XX X XXX XXXXX XX XX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 144 552 Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 145 552 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop PRV Rendering Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01. Example PRV PE PXC XXXXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 146 552 2310B Rendering Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF G2 XXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 147 552 2310C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_4 |
do not send. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01. Example PRV PE PXC XXXXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 146 552 2310B Rendering Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF G2 XXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 147 552 2310C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 77 2 XXXX XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 148 552 NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 149 552 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXXXXX XXX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 150 552 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXX XX XXXXXXXX XXX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 151 552 REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU X Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 152 552 PER 2750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop PER Service Facility Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is different than the information provided in Loop ID-1000A Submitter EDI Contact Information PER Segment, and Loop ID-2010AA Billing Provider Contact Information PER segment and when deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC XXXXXX TE XXXXXX EX XXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 153 552 2310C Service Facility Location Name Loop end Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 154 552 2310D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Supervising Provider Name Loop NM1 Supervising Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 DQ 1 XX XXX X X XX XXXX If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Supervising Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 155 552 NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 156 552 2310D Supervising Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Supervising Provider Name Loop REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF LU XXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 157 552 2310E Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Drop-off Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Pick- up Location Loop NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 PW 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 158 552 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Pick-up Location Loop N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 X XXXX Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 159 552 2310E Ambulance Pick-up Location Loop end N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Pick-up Location Loop N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXX XX Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 160 552 2310F Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Drop- off Location Loop NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 45 2 XXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 161 552 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Drop-off Location Loop N3 Ambulance Drop-off Location Address To specify the location of the named party Example N3 XXXXX XXXXXX Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 162 552 2310F Ambulance Drop-off Location Loop end N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Ambulance Drop-off Location Loop N4 Ambulance Drop-off Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XX XX XXXXXXX XXX Only one of Ambulance Drop-off State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Drop-off City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Drop-off State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Drop-off Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 163 552 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR H 39 XXX XX 14 CI Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. 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 This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 164 552 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 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) Medicare Risk 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 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 165 552 MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 166 552 CAS 2950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS OA XXX 0000 00000000 X 000000 0000000000 X X 0 000000000000000 XXXXX 00000000000000 000 XX 0 0000000 000000 XXXXX 00000000000000 000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 167 552 OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 168 552 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 169 552 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT D 00000 Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 170 552 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT A8 00 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 171 552 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 000000000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 172 552 OI 3100 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI W P I Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes OI-04 1351 Patient Signature Source Code Identifier (ID) Optional Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider Usage notes This is a crosswalk from CLM10 when doing COB. P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 173 552 MOA 3200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA 0000 000000000 XXX XX XXXXXX XXX X 0000000 00 00000000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 174 552 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA09 is the professional component amount billed but not payable. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 175 552 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 IL 1 X XXXXXX XXXXXX XXX II XXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 176 552 Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 177 552 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3 XX XXX Max use 1 Optional N3-01 166 Other Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 178 552 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4 XXXXXX XX XXXXXX XXX Only one of Other Subscriber State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Subscriber State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_5 |
Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 177 552 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3 XX XXX Max use 1 Optional N3-01 166 Other Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 178 552 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4 XXXXXX XX XXXXXX XXX Only one of Other Subscriber State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Subscriber State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 179 552 2330A Other Subscriber Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY XXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 180 552 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 PR 2 XXXX XV XXXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 181 552 NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 182 552 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N3 Other Payer Address To specify the location of the named party Usage notes 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. Example N3 XXX XXXX Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 183 552 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4 XX XX XXX XXX Only one of Other Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 184 552 DTP 3450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP 573 D8 XXX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 185 552 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REF T4 X Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The only valid value for this element is Y'. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 186 552 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REF F8 XXXXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 187 552 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REF G1 XXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 188 552 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF 9F XXXXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 189 552 2330B Other Payer Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF 2U XXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 190 552 2330C Other Payer Referring Provider Loop Max 2 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Referring Provider Loop NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 DN 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 191 552 2330C Other Payer Referring Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Referring Provider Loop REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF 0B XXXXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 192 552 2330D Other Payer Rendering Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Rendering Provider Loop NM1 Other Payer Rendering Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 82 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 193 552 2330D Other Payer Rendering Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Rendering Provider Loop REF Other Payer Rendering Provider Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF 1G XXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 194 552 2330E Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 77 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 195 552 2330E Other Payer Service Facility Location Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Service Facility Location Loop REF Other Payer Service Facility Location Secondary Identification To specify identifying information Example REF G2 XXXXXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 196 552 2330F Other Payer Supervising Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Billing Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Supervising Provider Loop NM1 Other Payer Supervising Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. Example NM1 DQ 1 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 197 552 2330F Other Payer Supervising Provider Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Supervising Provider Loop REF Other Payer Supervising Provider Secondary Identification To specify identifying information Example REF 1G XXXXXX Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Supervising Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 198 552 2330G Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Billing Provider Loop NM1 Other Payer Billing Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider 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. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 85 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 199 552 2330G Other Payer Billing Provider Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Billing Provider Loop REF Other Payer Billing Provider Secondary Identification To specify identifying information Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF G2 XXXX Max use 2 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Billing Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 200 552 2400 Service Line Number Loop Max 50 Required LX 3650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX 0000 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 201 552 SV1 3700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV1 Professional Service To specify the service line item detail for a health care professional Example SV1 IV XXXXX XX XX XX XX XXXX 0000000 MJ 000 X 0 0 0 00 0 Y Y Y 0 Max use 1 Required SV1-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting or adjudication processes. The NDC number is reported in the LIN segment of Loop ID- 2410 only. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 202 552 If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV1-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV102 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and or postage claimed amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV1-03 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes Required for Anesthesia claims. Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre- anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 203 552 the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel. UN Unit SV1-04 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV1-05 1331 Place of Service Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. SV105 is the place of service. Usage notes See CODE SOURCE 237: Place of Service Codes for Professional Claims SV1-07 C004 Composite Diagnosis Code Pointer To identify one or more diagnosis code pointers Max use 1 Required C004-01 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Required A pointer to the diagnosis code in the order of importance to this service C004-01 identifies the primary diagnosis code for this service line. Usage notes This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300. C004-02 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-02 identifies the second diagnosis code for this service line. C004-03 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-03 identifies the third diagnosis code for this service line. C004-04 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-04 identifies the fourth diagnosis code for this service line. SV1-09 1073 Emergency Indicator Identifier (ID) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 204 552 Code indicating a Yes or No condition or response SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related. Usage notes For this implementation, the listed value takes precedence over the semantic note. Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Y Yes SV1-11 1073 EPSDT Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. When this element is used, this service is not the screening service. Y Yes SV1-12 1073 Family Planning Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes SV1-15 1327 Co-Pay Status Code Identifier (ID) Optional Code indicating whether or not co-payment requirements were met on a line by line basis 0 Copay exempt 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 205 552 SV5 4000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV5 Durable Medical Equipment Service To specify the claim service detail for durable medical equipment Usage notes Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send. Example SV5 HC X DA 000000000000 000000000000000 00000 0 6 Max use 1 Optional SV5-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Procedure Identifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This value must be the same as that reported in SV101-2. SV5-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days SV5-03 380 Length of Medical Necessity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SV503 is the length of medical treatment required. SV5-04 782 DME Rental Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV504 is the rental price. SV5-05 782 DME Purchase Price Min 1 Max 15 Decimal number (R) Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 206 552 Monetary amount SV505 is the purchase price. SV5-06 594 Rental Unit Price Indicator Identifier (ID) Required Code indicating frequency or type of activities or actions being reported SV506 is the frequency at which the rental equipment is billed. 1 Weekly 4 Monthly 6 Daily 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 207 552 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Durable Medical Equipment Certificate of Medical Necessity Indicator To identify the type or transmission or both of paperwork or supporting information Usage notes Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.; Example PWK CT AF Variants (all may be used) PWK Line Supplemental Information Max use 1 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item CT Certification PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AB Previously Submitted to Payer AD Certification Included in this Claim AF Narrative Segment Included in this Claim AG No Documentation is Required NS Not Specified NS Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 208 552 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK 05 FT AC XXXXXX Variants (all may be used) PWK Durable Medical Equipment Certificate of Medical Necessity Indicator If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 or Medicare Secondary Payor) 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 209 552 HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_6 |
AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 208 552 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK 05 FT AC XXXXXX Variants (all may be used) PWK Durable Medical Equipment Certificate of Medical Necessity Indicator If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 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 or Medicare Secondary Payor) 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 209 552 HC Health Certificate HR Health Clinic Records I5 Immunization Record 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 vital signs) 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 Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 210 552 For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 211 552 CR1 4250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CR1 LB 0000 A DH 00 X XXXXXX If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CR106 is the distance traveled during transport. Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 212 552 CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 213 552 CR3 4350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CR3 Durable Medical Equipment Certification To supply information regarding a physician's certification for durable medical equipment Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example CR3 R MO 00000000000000 Max use 1 Optional CR3-01 1322 Certification Type Code Identifier (ID) Required Code indicating the type of certification I Initial R Renewal S Revised CR3-02 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken CR302 and CR303 specify the time period covered by this certification. MO Months CR3-03 380 Durable Medical Equipment Duration Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Length of time DME equipment is needed. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 214 552 CRC 4500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CRC Ambulance Certification To supply information on conditions Usage notes The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CRC 07 N 06 XX XX XXX XX Variants (all may be used) CRC Condition Indicator Durable Medical Equipment CRC Hospice Employee Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 215 552 Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 216 552 CRC 4500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CRC Condition Indicator Durable Medical Equipment To supply information on conditions Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The first example shows a case where an item billed was not a replacement item. Example CRC 09 Y ZV XX Variants (all may be used) CRC Ambulance Certification CRC Hospice Employee Indicator Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 09 Durable Medical Equipment Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 38 Certification signed by the physician is on file at the supplier's office ZV Replacement Item CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 217 552 CRC 4500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CRC Hospice Employee Indicator To supply information on conditions Usage notes Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The example shows the method used to indicate whether the rendering provider is an employee of the hospice. Example CRC 70 N 65 Variants (all may be used) CRC Ambulance Certification CRC Condition Indicator Durable Medical Equipment Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 70 Hospice CRC-02 1073 Hospice Employed Provider Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes A "Y" value indicates the provider is employed by the hospice. A "N" value indicates the provider is not employed by the hospice. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 218 552 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Begin Therapy Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example DTP 463 D8 XXX Variants (all may be used) DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 463 Begin Therapy DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Begin Therapy Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 219 552 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP DATE - Certification Revision Recertification Date To specify any or all of a date, a time, or a time period Usage notes Required when CR301 (DMERC Certification) "R" or "S". If not required by this implementation guide, do not send. Example DTP 607 D8 XXXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 607 Certification Revision DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Certification Revision or Recertification Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 220 552 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send. Example DTP 454 D8 XX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 221 552 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Last Certification Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF). Example DTP 461 D8 XXXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 461 Last Certification DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Certification Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 222 552 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when a claim involves physician services for routine foot care; and is different than the date listed at the claim level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.; Example DTP 304 D8 XXXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Treatment or Therapy Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 223 552 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example DTP 455 D8 XXXXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 224 552 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send. Example DTP 471 D8 XXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Service Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 225 552 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and 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 first day of the drug used by the patient is 1 1 00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was 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 supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1 1 00. Example DTP 472 D8 XXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Shipped Date DTP Date - Test Date Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 226 552 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Shipped Date To specify any or all of a date, a time, or a time period Usage notes Required when billing or reporting shipped products. If not required by this implementation guide, do not send. Example DTP 011 D8 XXXXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Test Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 011 Shipped DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Shipped Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 227 552 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Test Date To specify any or all of a date, a time, or a time period Usage notes Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send. Example DTP 739 D8 XXXXXX Variants (all may be used) DTP Date - Begin Therapy Date DTP DATE - Certification Revision Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Prescription Date DTP Date - Service Date DTP Date - Shipped Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 738 Most Recent Hemoglobin or Hematocrit or Both 739 Most Recent Serum Creatine DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Test Performed Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 228 552 QTY 4600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop QTY Ambulance Patient Count To specify quantity information Usage notes Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. The QTY02 is the only place to report the number of patients when there are multiple patients transported. Example QTY PT 000 Variants (all may be used) QTY Obstetric Anesthesia Additional Units Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity PT Patients QTY-02 380 Ambulance Patient Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 229 552 QTY 4600 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop QTY Obstetric Anesthesia Additional Units To specify quantity information Usage notes Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time. If not required by this implementation guide, do not send. Example QTY FL 00000000 Variants (all may be used) QTY Ambulance Patient Count Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity FL Units QTY-02 380 Obstetric Additional Units Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The number of additional units reported by an anesthesia provider to reflect additional complexity of services. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 230 552 MEA 4620 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop MEA Test Result To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001) Usage notes Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results. OR Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier. If not required by this implementation guide, do not send. Example MEA TR HT 0000 Max use 5 Optional MEA-01 737 Measurement Reference Identification Code Identifier (ID) Required Code identifying the broad category to which a measurement applies OG Original Use OG to report Starting Dosage. TR Test Results MEA-02 738 Measurement Qualifier Identifier (ID) Required Code identifying a specific product or process characteristic to which a measurement applies HT Height R1 Hemoglobin R2 Hematocrit R3 Epoetin Starting Dosage R4 Creatinine MEA-03 739 Test Results Min 1 Max 15 Decimal number (R) Required The value of the measurement 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 231 552 CN1 4650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet 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. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN1 09 000000000000000 0 XXX 00 XXXXXX Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 232 552 CN106 is an additional identifying number for the contract. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 233 552 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9D X Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 234 552 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID- 2300). If not required by this implementation guide, do not send.; Example REF X4 XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 235 552 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Immunization Batch Number To specify identifying information Usage notes Required when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send. Example REF BT XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification BT Batch Number REF-02 127 Immunization Batch Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 236 552 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF 6R XXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 237 552 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send. Example REF EW X Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 238 552 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Prior Authorization To specify identifying information Usage notes Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number. Example REF G1 XX 2U XXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization or Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 239 552 Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 240 552 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Referral Number To specify identifying information Usage notes Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number. Example REF 9F XXX 2U XXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Referral Number reported in REF02 of this segment is for a non- destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_7 |
Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 239 552 Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 240 552 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Referral Number To specify identifying information Usage notes Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number. Example REF 9F XXX 2U XXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the Referral Number reported in REF02 of this segment is for a non- destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 241 552 Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 242 552 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification To specify identifying information Usage notes Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send. Example REF F4 XX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F4 Facility Certification Number REF-02 127 Referring CLIA Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 243 552 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9B X Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Prior Authorization REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 244 552 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Postage Claimed Amount To indicate the total monetary amount Usage notes Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send. When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount. Example AMT F4 0000000 Variants (all may be used) AMT Sales Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F4 Postage Claimed AMT-02 782 Postage Claimed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 245 552 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Sales Tax Amount To indicate the total monetary amount Usage notes Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount. Example AMT T 000000000000000 Variants (all may be used) AMT Postage Claimed Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount T Tax AMT-02 782 Sales Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 246 552 K3 4800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop K3 File Information To transmit a fixed-format record or matrix contents Usage notes 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. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3 XXXXX Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 247 552 NTE 4850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop NTE Line Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description. Example NTE ADD XXXXX Variants (all may be used) NTE Third Party Organization Notes Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information DCP Goals, Rehabilitation Potential, or Discharge Plans NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 248 552 NTE 4850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTE TPO XXXXX Variants (all may be used) NTE Line Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 249 552 PS1 4880 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop PS1 Purchased Service Information To specify the information about services that are purchased Usage notes Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source. OR Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses. If not required by this implementation guide, do not send. Example PS1 XXXXX 00000000000000 Max use 1 Optional PS1-01 127 Purchased Service Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PS101 is provider identification number. Usage notes This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109. PS1-02 782 Purchased Service Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PS102 is cost of the purchased service. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 250 552 HCP 4920 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop HCP Line Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example HCP 03 000 00 XXXXX 00000 XX 00000000000 IV XX X MJ 000 T4 3 2 If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 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 Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 251 552 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. HCP-05 118 Repricing Per Diem or Flat Rate Amount Min 1 Max 9 Decimal number (R) Optional Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. HCP-06 127 Repriced Approved Ambulatory Patient Group Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. HCP-07 782 Repriced Approved Ambulatory Patient Group Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type source of the descriptive number used in Product Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 252 552 OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP10 is the approved procedure code. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken MJ Minutes UN Unit HCP-12 380 Repriced Approved Service Unit Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 253 552 5 State Mandates 6 Other 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 254 552 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop LIN Drug Identification To specify basic item identification data Usage notes Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN's. If not required by this implementation guide, do not send. Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400. Example LIN UP XXXXX Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) LIN02 through LIN31 provide for fifteen different product service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. Usage notes At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation. EN EAN UCC - 13 EO EAN UCC - 8 HI HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message N4 National Drug Code in 5-4-2 Format ON Customer Order Number UK GTIN 14-digit Data Structure UP UCC - 12 LIN-03 234 National Drug Code or Universal Product Number Min 1 Max 48 String (AN) Required Identifying number for a product or service 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 255 552 CTP 4940 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop CTP Drug Quantity To specify pricing information Example CTP 0 ML Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 256 552 2410 Drug Identification Loop end REF 4950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop REF Prescription or Compound Drug Association Number To specify identifying information Usage notes Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REF VY XXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 257 552 2420A Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. OR Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID- 2010AA Billing Provider. If not required by this implementation guide, do not send.; Example NM1 82 2 XXXXXX XXXXX XXXXX XXXXXX XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 258 552 NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 259 552 PRV 5050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop PRV Rendering Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRV PE PXC XXXXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 260 552 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G X 2U XX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 261 552 2420A Rendering Provider Name Loop end Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 262 552 2420B Purchased Service Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Purchased Service Provider Name Loop NM1 Purchased Service Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send. Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations. Example NM1 QB 2 XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Purchased Service Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. QB Purchase Service Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Purchased Service Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 263 552 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Purchased Service Provider Name Loop REF Purchased Service Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF G2 XXXX 2U XXXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Purchased Service Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 264 552 2420B Purchased Service Provider Name Loop end The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 265 552 2420C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.; Example NM1 77 2 XXXXX XX XX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 266 552 XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 267 552 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXXXX XXXXXX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 268 552 N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXXX XX XXXXXXX XX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 269 552 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF LU XXX 2U X Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Service Facility Location Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 270 552 2420C Service Facility Location Name Loop end 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 271 552 2420D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Supervising Provider Name Loop NM1 Supervising Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send. Example NM1 DQ 1 XXXXXX X XX X XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Supervising Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 272 552 Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 273 552 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Supervising Provider Name Loop REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF G2 XXXXXX 2U XXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_8 |
organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 272 552 Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 273 552 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Supervising Provider Name Loop REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF G2 XXXXXX 2U XXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 274 552 2420D Supervising Provider Name Loop end Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 275 552 2420E Ordering Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop NM1 Ordering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send. Example NM1 DK 1 XXXXX XX XXXX XX XX XXXX If either Identification Code Qualifier (NM1-08) or Ordering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. DK Ordering Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Ordering Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Ordering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Ordering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Ordering Provider Name Suffix Min 1 Max 10 String (AN) Optional 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 276 552 Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Ordering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 277 552 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop N3 Ordering Provider Address To specify the location of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N3 XX X Max use 1 Optional N3-01 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 278 552 N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop N4 Ordering Provider City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N4 XXXXX XX XXXXXX XX Only one of Ordering Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Ordering Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ordering Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ordering Provider Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 279 552 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop REF Ordering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXXX 2U XXXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Ordering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 280 552 The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 281 552 PER 5300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ordering Provider Name Loop PER Ordering Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC XXXX EM XX EM XXXX TE XX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Ordering Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 282 552 2420E Ordering Provider Name Loop end PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 283 552 2420F Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed reported in this transaction. Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example NM1 P3 1 XXXXX X XX XX XX XXXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 284 552 NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 285 552 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXXXXX 2U XXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 286 552 2420F Referring Provider Name Loop end The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 287 552 2420G Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Drop-off Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Pick-up Location Loop NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.; Example NM1 PW 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 288 552 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Pick-up Location Loop N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXXXX X Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 289 552 2420G Ambulance Pick-up Location Loop end N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Pick-up Location Loop N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXXX XX Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 290 552 2420H Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Drop-off Location Loop NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send. Example NM1 45 2 XXXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 291 552 N3 5140 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Drop-off Location Loop N3 Ambulance Drop-off Location Address To specify the location of the named party Usage notes If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XXX XXXXX Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 292 552 2420H Ambulance Drop-off Location Loop end N4 5200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Ambulance Drop-off Location Loop N4 Ambulance Drop-off Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXXXXXXX XXX Only one of Ambulance Drop-off State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Drop-off City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Drop-off State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Drop-off Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 293 552 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD XXXXXXX 00000000000 IV XX XX XX XX XX XXXXXX 000000000 00 Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 294 552 OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 295 552 C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled or Unbundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 296 552 CAS 5450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS CO X 0 0 XXXX 00000000000000 00000000000000 X X 0000000000 000000000000 XXX 0000000000000 00 XX X 000000 0 XXXX 00000 000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 297 552 Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 298 552 See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 299 552 DTP 5500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP 573 D8 XXXXXX Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 300 552 2430 Line Adjudication Information Loop end AMT 5505 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 301 552 2440 Form Identification Code Loop Max 1 Optional LQ 5510 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Form Identification Code Loop LQ Form Identification Code To identify standard industry codes Usage notes Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send. Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01 UT which identifies the form as a Medicare DMERC CMN form. LQ02 01.02 identifies which DMERC CMN form is being used. An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services. Example LQ UT XXXX Max use 1 Required LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list AS Form Type Code Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02. UT Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms LQ-02 1271 Form Identifier Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 302 552 2440 Form Identification Code Loop end FRM 5520 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Form Identification Code Loop FRM Supporting Documentation To specify information in response to a codified questionnaire document Usage notes The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes No questions, FRM03 for text uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQUT08.02 ). Example FRM XXXXXX Y X 20250131 00 At least one of Question Response (FRM-02), Question Response (FRM-03), Question Response (FRM-04) or Question Response (FRM-05) is required Max use 99 Required FRM-01 350 Question Number Letter Min 1 Max 20 String (AN) Required Alphanumeric characters assigned for differentiation within a transaction set FRM01 is the question number on a questionnaire or codified form. FRM-02 1073 Question Response Identifier (ID) Optional Code indicating a Yes or No condition or response FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01. N No W Not Applicable Y Yes FRM-03 127 Question Response Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier FRM-04 373 Question Response CCYYMMDD format Date (DT) Optional Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year FRM-05 332 Question Response Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 303 552 2400 Service Line Number Loop end 2300 Claim Information Loop end 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 304 552 2000C Patient Hierarchical Level Loop Max 1 Optional HL 0010 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 3 2 23 0 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 23 Dependent HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 0 No Subordinate HL Segment in | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_9 |
codified form. FRM-02 1073 Question Response Identifier (ID) Optional Code indicating a Yes or No condition or response FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01. N No W Not Applicable Y Yes FRM-03 127 Question Response Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier FRM-04 373 Question Response CCYYMMDD format Date (DT) Optional Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year FRM-05 332 Question Response Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0 through 100 ) 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 303 552 2400 Service Line Number Loop end 2300 Claim Information Loop end 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 304 552 2000C Patient Hierarchical Level Loop Max 1 Optional HL 0010 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 3 2 23 0 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 23 Dependent HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 305 552 PAT 0070 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop PAT Patient Information To supply patient information Example PAT 01 D8 X 01 000000000 Y If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required Max use 1 Required PAT-01 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities Usage notes Specifies the patient's relationship to the person insured. 01 Spouse 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship PAT-05 1250 Date Time Period Format Qualifier Identifier (ID) Optional Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD PAT-06 1251 Patient Death Date Min 1 Max 35 String (AN) Optional Expression of a date, a time, or range of dates, times or dates and times PAT06 is the date of death. PAT-07 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken 01 Actual Pounds PAT-08 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight PAT08 is the patient's weight. PAT-09 1073 Pregnancy Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant. Usage notes 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 306 552 For this implementation, the listed value takes precedence over the semantic note. Y Yes 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 307 552 2010CA Patient Name Loop Max 1 Required NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop NM1 Patient Name To supply the full name of an individual or organizational entity Example NM1 QC 1 XXXXX X XXX XX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 308 552 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop N3 Patient Address To specify the location of the named party Example N3 XXX XXXXX Max use 1 Required N3-01 166 Patient Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Patient Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 309 552 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop N4 Patient City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXXXXX XX XXXXX XX Only one of Patient State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Patient City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Patient State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Patient Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 310 552 DMG 0320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop DMG Patient Demographic Information To supply demographic information Example DMG D8 XXXXXX U Max use 1 Required DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Patient Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Patient Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 311 552 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop REF Property and Casualty Claim Number To specify identifying information Usage notes Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Example REF Y4 XXXX Variants (all may be used) REF Property and Casualty Patient Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 312 552 REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop REF Property and Casualty Patient Identifier To specify identifying information Usage notes Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send. Example REF 1W XXXXX Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1W Member Identification Number This code designates a patient identification number used by the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Property and Casualty Patient Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 313 552 PER 0400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Patient Name Loop PER Property and Casualty Patient Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is different than the information provided in the Subscriber Contact Information PER segment in Loop ID- 2010BA and this information is deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER IC XXXX TE XXXX EX XXXXXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 314 552 2010CA Patient Name Loop end 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 315 552 2300 Claim Information Loop Max 100 Required CLM 1300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. 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 hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLM X 0000000000000 XX B X N A Y I P OA XX X X XXX 03 2 Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is 20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 316 552 CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Place of Service Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. B Place of Service Codes for Professional or Dental Services C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-06 1073 Provider or Supplier Signature Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file. N No Y Yes CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 317 552 Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-10 1351 Patient Signature Source Code Identifier (ID) Optional Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. CLM-11 C024 Related Causes Information To identify one or more related causes and associated state or country information Usage notes Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send. Max use 1 Optional C024-01 1362 Related Causes Code Identifier (ID) Required Code identifying an accompanying cause of an illness, injury or an accident AA Auto Accident EM Employment OA Other Accident C024-02 1362 Related Causes Code Min 2 Max 3 Identifier (ID) Optional Code identifying an accompanying cause of an illness, injury or an accident C024-04 156 Auto Accident State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA". 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 318 552 C024-05 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country CLM-12 1366 Special Program Indicator Identifier (ID) Optional Code indicating the Special Program under which the services rendered to the patient were performed 02 Physically Handicapped Children's Program This code is used for Medicaid claims only. 03 Special Federal Funding This code is used for Medicaid claims only. 05 Disability This code is used for Medicaid claims only. 09 Second Opinion or Surgery This code is used for Medicaid claims only. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 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 Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 319 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Accident To specify any or all of a date, a time, or a time period Usage notes Required when CLM11-1 or CLM11-2 has a value of AA' or OA'. OR Required when CLM11-1 or CLM11-2 has a value of EM' and this claim is the result of an accident. If not required by this implementation guide, do not send. Example DTP 439 D8 XXXX Variants (all may be used) DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 439 Accident DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Accident Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 320 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Acute Manifestation To specify any or all of a date, a time, or a time period Usage notes Required when Loop ID-2300 CR208 "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send. Example DTP 453 D8 XXX Variants (all may be used) DTP Date - Accident DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 453 Acute Manifestation of a Chronic Condition DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Acute Manifestation Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 321 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Admission To specify any or all of a date, a time, or a time period Usage notes Required on all ambulance claims when the patient was known to be admitted to the hospital. OR Required on all claims involving inpatient medical visits. If not required by this implementation guide, do not send. Example DTP 435 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Admission Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 322 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Assumed and Relinquished Care Dates To specify any or all of a date, a time, or a time period Usage notes Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send. Assumed Care Date is the date care was assumed by another provider during post- operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A". Example DTP 091 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 090 Report Start Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care. 091 Report End Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Assumed or Relinquished Care Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 323 552 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 324 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Authorized Return to Work To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP 296 D8 XXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 296 Initial Disability Period Return To Work This is the date the provider has authorized the patient to return to work. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Work Return Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 325 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Disability Dates To specify any or all of a date, a time, or a time period Usage notes Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his her work. OR Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor. If not required by this implementation guide, do not send. Example DTP 314 D8 XXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 314 Disability Use code 314 when both disability start and end date are being reported. 360 Initial Disability Period Start Use code 360 if patient is currently disabled and disability end date is unknown. 361 Initial Disability Period End Use code 361 if patient is no longer disabled and the start date is unknown. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD Use code D8 when DTP01 is 360 or 361. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use code RD8 when DTP01 is 314. DTP-03 1251 Disability From Date Min 1 Max 35 String (AN) Required 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 326 552 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 327 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Discharge To specify any or all of a date, a time, or a time period Usage notes Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send. Example DTP 096 D8 XXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Discharge Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 328 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Hearing and Vision Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send. Example DTP 471 D8 XXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 329 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 454 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 330 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Last Menstrual Period To specify any or all of a date, a time, or a time period Usage notes Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send. Example DTP 484 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 484 Last Menstrual Period DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Menstrual Period Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 331 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP 304 D8 XXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Seen Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 332 552 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Last Worked To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP 297 D8 XXXXXX Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 297 Initial Disability Period Last Day Worked DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Worked Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 333 552 DTP 1350 Detail Billing Provider Hierarchical | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_10 |
Subsets and Splits